Stop All Antibiotics—This Is Post-Infectious Cough, Not Bacterial Infection
Antibiotics are explicitly contraindicated for post-infectious cough and should be discontinued immediately. 1, 2 Your patient has classic post-infectious cough following successful pneumonia treatment, and continuing levofloxacin and amoxicillin provides zero clinical benefit while contributing to antimicrobial resistance and adverse effects. 2, 3
Understanding the Clinical Situation
Post-infectious cough is an expected, self-limited phenomenon that commonly persists 3–8 weeks after completing pneumonia treatment, caused by ongoing airway inflammation and hyperresponsiveness—not ongoing infection. 2 The pathogenesis involves:
- Bronchial hyperresponsiveness triggered by the initial infection 1, 2
- Mucus hypersecretion and impaired mucociliary clearance 1, 2
- Upper airway inflammation 1
- Increased sensitivity to inhaled irritants 1
First-Line Treatment Algorithm
Start inhaled ipratropium bromide 2–3 puffs (17–34 mcg per puff) four times daily. 2, 3 This has the strongest evidence in controlled trials for attenuating post-infectious cough, with clinical response expected within 1–2 weeks. 2, 4
Second-Line Treatment (If Cough Persists Despite Ipratropium)
Add an inhaled corticosteroid (fluticasone 220 mcg or budesonide 360 mcg twice daily) when cough continues and adversely affects quality of life. 2, 3 Allow up to 8 weeks for full therapeutic response. 2
Third-Line Treatment (For Severe Cases Only)
Oral prednisone 30–40 mg daily for 5–10 days is reserved exclusively for severe, quality-of-life-impairing paroxysms, and only after exclusion of upper airway cough syndrome, asthma, and GERD. 1, 2, 4
Critical Rule-Out: Pertussis
Given the 2-week duration with persistent cough, pertussis must be excluded. 4 Pertussis should be suspected when cough lasts ≥2 weeks with paroxysms, post-tussive vomiting, or inspiratory "whoop." 1, 2, 4 If clinical suspicion exists:
- Obtain nasopharyngeal aspirate or Dacron swab for culture immediately 4
- Start empiric macrolide therapy (erythromycin 1–2 g/day for 2 weeks, or azithromycin/clarithromycin as better-tolerated alternatives) without waiting for culture results 4
- Institute 5-day home isolation after starting antibiotics 4
When to Obtain Chest X-Ray
Order chest radiography if: 3
- Cough persists beyond 8 weeks total duration
- Any red flags develop: hemoptysis, fever, weight loss, night sweats, or worsening symptoms
- New focal findings on exam (crackles, diminished breath sounds, dullness to percussion)
Transition to Chronic Cough Evaluation (Beyond 8 Weeks)
If cough persists beyond 8 weeks, it must be reclassified as chronic cough and systematically evaluated for: 2, 4, 3
- Upper airway cough syndrome (UACS) – treat with first-generation antihistamine-decongestant combination plus intranasal corticosteroid spray; response expected in days to 1–2 weeks 2, 3
- Asthma/cough-variant asthma – consider bronchoprovocation challenge or empiric trial of inhaled corticosteroids plus beta-agonists; response may take up to 8 weeks 2
- GERD – initiate high-dose PPI therapy (omeprazole 40 mg twice daily) with dietary modifications; response may require 2 weeks to several months 2
Common Pitfalls to Avoid
- Do NOT continue or add more antibiotics. 1, 2, 3 Therapy with antibiotics has no role in post-infectious cough, as the cause is not bacterial infection. 1, 2
- Do NOT jump to oral prednisone for mild post-infectious cough; reserve it for severe cases that have failed other therapies. 2, 4
- Do NOT fail to recognize when cough has persisted beyond 8 weeks, which requires reclassification as chronic cough and systematic evaluation for UACS, asthma, and GERD. 2, 4
Red Flags Requiring Immediate Re-Evaluation
Instruct the patient to return immediately if: 3
- Fever develops
- Hemoptysis occurs
- Symptoms worsen despite treatment
- No improvement is seen within 3–5 days of starting ipratropium