What is the appropriate management for a healthy young man with severe cough, fever and sore throat, currently taking azithromycin, paracetamol, chlorpheniramine and povidone‑iodine mouth‑gargle, who has no clinical or radiographic evidence of pneumonia?

Management of Acute Respiratory Illness Without Pneumonia

Azithromycin should be discontinued immediately in this healthy young man with no clinical or radiographic evidence of pneumonia. 1

Discontinue Antibiotic Therapy

The 2019 CHEST guidelines explicitly state that where there is no clinical or radiographic evidence of pneumonia, routine use of antibiotics is not suggested. 1 This represents the highest quality and most recent guideline evidence directly addressing this clinical scenario.

• Antibiotics provide minimal benefit for viral upper respiratory infections and acute bronchitis without pneumonia, while contributing to antimicrobial resistance. 1
• The current azithromycin regimen is inappropriate because this patient lacks pneumonia on both clinical assessment and chest imaging. 1
• Macrolides like azithromycin have been associated with significantly more adverse events than placebo in patients with acute bronchitis. 1

Continue Symptomatic Management

The current symptomatic therapy is appropriate and should be continued:

• Paracetamol (acetaminophen) for fever and pain relief 1
• Chlorpheniramine (first-generation antihistamine) for symptomatic relief 1
• Povidone-iodine gargle for sore throat 1

Additional symptomatic options to consider include:

• Cough suppressants (dextromethorphan or codeine) 1
• Expectorants (guaifenesin) 1
• Decongestants (phenylephrine) if nasal congestion is prominent 1

Consider Influenza and Antiviral Therapy

If influenza is suspected and the patient is within 48 hours of symptom onset, consider oseltamivir 75 mg twice daily for 5 days. 1

• Antiviral treatment initiated within 48 hours of symptom onset is associated with decreased antibiotic use (38% vs 20%), reduced hospitalization, and improved outcomes. 1
• Treatment is most effective when started early, with significant reductions in mortality (OR 0.33) and hospitalization (OR 0.52) when given within 48 hours. 1
• Influenza should be suspected if the patient has fever >38°C, acute onset of symptoms, and is presenting during influenza season. 1

Assess for Streptococcal Pharyngitis

For the sore throat component, evaluate using modified Centor criteria to determine if bacterial pharyngitis testing is warranted:

• Fever by history
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough 1

If fewer than 3 Centor criteria are present, no testing for streptococcal pharyngitis is needed. 1 Given this patient has cough, bacterial pharyngitis is less likely and testing is not indicated. 1

Expected Clinical Course

• Most viral respiratory infections resolve within 7-10 days without antibiotics. 1
• Fever may persist for 2-4 days in healthy individuals with viral illness. 2
• The patient should be counseled that 82% of patients with sore throat are symptom-free by one week without antibiotics. 3

Red Flags Requiring Reassessment

Advise the patient to return if any of the following develop:

• Worsening dyspnea or respiratory distress 2, 4
• Persistent fever beyond 4-5 days 2
• Development of focal chest findings (new localized crackles, decreased breath sounds) 2, 4
• Oxygen saturation <90% 1
• Inability to maintain oral intake 1
• Altered mental status 1

Common Pitfalls to Avoid

• Do not continue antibiotics "just to complete the course" when pneumonia has been ruled out—this contributes to resistance without clinical benefit. 1
• Do not assume all febrile respiratory illnesses require antibiotics—the vast majority are viral and self-limited. 1, 3
• Do not add corticosteroids for symptomatic relief in this setting, as there is insufficient evidence for benefit in outpatient respiratory infections without pneumonia. 4