An 84‑year‑old patient taking cefdinir (300 mg) twice daily for 7 days and prednisone (20 mg) daily for 5 days remains febrile with cough; what next steps should I take?

Immediate Re-evaluation and Diagnostic Workup Required

This 84-year-old patient with persistent fever and cough after completing both cefdinir and prednisone requires urgent chest radiography to exclude pneumonia, followed by systematic evaluation for alternative diagnoses if imaging is normal. 1

Critical First Step: Rule Out Pneumonia

You must obtain a chest X-ray immediately because:

• Persistent fever beyond 4 days with cough in an 84-year-old raises the probability of community-acquired pneumonia to approximately 39% when focal findings are present 1
• The combination of age ≥65 years, persistent fever, and cough mandates radiographic confirmation before any further antibiotic changes 1
• Do not prescribe additional antibiotics until pneumonia is confirmed or excluded radiographically 1

Physical Examination Focus

Perform a targeted re-examination looking specifically for:

• Focal crackles, diminished breath sounds, or dullness to percussion – these findings increase pneumonia probability from 5-10% to 39% 1
• Respiratory rate >30 breaths/min, heart rate >100 bpm, or systolic BP <90 mmHg – these vital-sign abnormalities identify high-risk patients requiring hospitalization 1
• New confusion or altered mental status – a marker of severe disease in older adults 1

If Chest X-Ray Shows Pneumonia

Switch to appropriate pneumonia treatment:

• First-line agents are amoxicillin or a tetracycline (not cefdinir continuation) 1
• In β-lactam allergy, use a newer macrolide (azithromycin, clarithromycin) only if local pneumococcal macrolide resistance is low 1
• Obtain blood cultures and sputum culture before starting the new antibiotic 1
• Consider hospital admission given age ≥65 years and persistent fever 1

If Chest X-Ray Is Normal: Post-Infectious Cough Algorithm

Antibiotics are explicitly contraindicated – cefdinir has already been given for 7 days, and continuing or changing antibiotics provides no benefit because post-infectious cough is not bacterial 1, 2

Why Prednisone Failed

Prednisone was prescribed prematurely – it should be reserved as third-line therapy only after failure of both inhaled ipratropium and inhaled corticosteroids, and only for severe paroxysms that significantly impair quality of life 1, 2

Correct Treatment Sequence for Post-Infectious Cough

Step 1: Start inhaled ipratropium bromide

• Dose: 2-3 puffs (17-34 mcg per puff) four times daily 1
• This has the strongest evidence for attenuating post-infectious cough 1, 2
• Expected response time: 1-2 weeks 1

Step 2: If no improvement after 1-2 weeks, add inhaled corticosteroid

• Options: fluticasone 220 mcg or budesonide 360 mcg twice daily 1
• Allow up to 8 weeks for full response 1
• Continue ipratropium while adding the inhaled steroid 1

Step 3: Only if severe paroxysms persist despite Steps 1 & 2

• Oral prednisone 30-40 mg daily for 5-10 days 1, 2
• Must first rule out upper airway cough syndrome (UACS), asthma, and GERD 1, 2

Evaluate for Alternative Diagnoses Beyond 8 Weeks

If cough has now persisted >8 weeks total (from initial illness onset), reclassify as chronic cough and systematically evaluate:

Upper Airway Cough Syndrome (UACS)

• Start first-generation antihistamine-decongestant combination (e.g., brompheniramine/pseudoephedrine) plus intranasal corticosteroid spray (fluticasone or mometasone) 1
• Expected response: days to 1-2 weeks 1

Asthma (Including Cough-Variant Asthma)

• Consider bronchoprovocation challenge or empiric trial of inhaled corticosteroids plus beta-agonists 1
• Expected response: up to 8 weeks 1

GERD (Often "Silent" Without GI Symptoms)

• Initiate high-dose PPI therapy (omeprazole 40 mg twice daily) with dietary modifications 1
• Expected response: 2 weeks to several months 1

What NOT to Do

• Do not prescribe more antibiotics unless chest X-ray confirms pneumonia or you document bacterial sinusitis or early pertussis 1, 2
• Do not repeat oral prednisone without first completing the ipratropium → inhaled corticosteroid sequence 1, 2
• Do not use guaifenesin or dextromethorphan as primary therapy – these are supportive adjuncts only and do not address the underlying airway inflammation 1, 3

Red Flags Requiring Immediate Re-evaluation

Instruct the patient to return immediately if:

• Hemoptysis develops 1
• Increasing dyspnea or tachypnea occurs 1
• Fever worsens or new confusion appears 1
• Weight loss or night sweats emerge (consider tuberculosis in this age group) 1

Common Pitfall in This Case

The most likely error was jumping to prednisone without first trying inhaled ipratropium – the evidence-based algorithm places ipratropium as first-line and reserves oral steroids for refractory cases after inhaled therapies fail 1, 2. The patient may simply need the correct sequence of treatments rather than more aggressive systemic therapy.