Antibiotic Use in Acute Cough

Introduction to Antibiotic Indications

Antibiotics are rarely indicated for acute cough and should only be prescribed for specific conditions, including confirmed bacterial pneumonia, pertussis, bacterial sinusitis, and exacerbations of bronchiectasis or severe chronic bronchitis in patients with severe airflow obstruction, as recommended by the American Academy of Family Physicians and the American College of Chest Physicians 1, 2
The American College of Chest Physicians suggests that antibiotics should be used when pneumonia is suspected in settings where imaging cannot be obtained, with a high level of evidence 2

Suspect pertussis when cough persists >2 weeks with paroxysmal coughing, post-tussive vomiting, and inspiratory whooping sound, according to the American College of Chest Physicians 3
Evaluate for pneumonia-suggestive features, such as cough, dyspnea, pleural pain, fever ≥38°C, absence of runny nose, tachypnea, and new and localizing chest examination findings, as recommended by the American College of Chest Physicians 2
The presence of cough with green/purulent sputum is 94% sensitive for high bacterial load, and clinical features such as fever ≥38°C, dyspnea, pleural pain, and absence of runny nose can suggest pneumonia, according to the American Thoracic Society, with a strength of evidence based on observational studies 2, 4, 5

Macrolide antibiotics (erythromycin, azithromycin, or clarithromycin) should be given to confirmed cases and probable cases of pertussis with epidemiologic linkage to a confirmed case, as recommended by the American College of Chest Physicians 3
Azithromycin is a preferred first-line option for most outpatients with pneumonia, with a standard duration of 5 days (500 mg day 1, 250 mg days 2-5), as recommended by the American College of Chest Physicians 2
Beta-lactam options, such as amoxicillin-clavulanate, can be considered for patients with purulent sputum or other risk factors, as suggested by the American College of Chest Physicians 2
For patients with no risk factors for multidrug-resistant (MDR) pathogens, narrow-spectrum antibiotics such as ertapenem, ceftriaxone, or cefotaxime can be considered as alternative options, as recommended by the European Respiratory Society, with a moderate level of evidence 6

Antibiotics are indicated for bacterial sinusitis causing upper airway cough syndrome, as recommended by the American Academy of Family Physicians 1
Exacerbations of bronchiectasis and severe chronic bronchitis in current or previous smokers with severe airflow obstruction may require antibiotic treatment, as recommended by the American Academy of Family Physicians 1
Bacterial bronchiolitis: Prolonged antibiotic therapy improves cough, according to the American College of Chest Physicians 7
Diffuse panbronchiolitis (DPB): Prolonged treatment (≥2-6 months) with macrolides is indicated, as suggested by the American College of Chest Physicians 7

Routine treatment with antibiotics is not justified for acute bronchitis, as recommended by the American College of Chest Physicians 8
Antibiotics are not indicated for acute cough from the common cold, according to the American Academy of Family Physicians 1
First-generation antihistamine/decongestant or naproxen may be more appropriate for acute cough from the common cold, as suggested by the American Academy of Family Physicians 1
Adequate hydration, rest, and analgesics for pleuritic pain are recommended for patients with suspected pneumonia, as suggested by the American College of Chest Physicians 5
Oxygen therapy should be used if hypoxemic to maintain SaO₂ >92%, as recommended by the American Thoracic Society 5

Failure to reassess and evaluate clinical response after 48-72 hours can lead to inadequate treatment, as emphasized by the Infectious Diseases Society of America, with a strong level of evidence 9
Inadequate assessment of severity can lead to inappropriate treatment, and careful evaluation for signs requiring hospitalization is necessary, as emphasized by the American College of Chest Physicians and the Infectious Diseases Society of America 2, 5
Not prescribing antibiotics without radiographic evidence of pneumonia can help prevent antibiotic resistance, as stated by the American College of Chest Physicians, with a high level of evidence 2