Approach to Patient with Cough and Fever

Initial Assessment

The American Thoracic Society recommends performing a focused medical history to determine if the patient is taking an ACE inhibitor, is a smoker, or has evidence of serious life-threatening systemic disease 1, 2
The British Infection Association suggests assessing for signs of respiratory distress including markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs, cyanosis, severe dehydration, altered conscious level, or complicated seizures 3
The British Medical Association advises evaluating for risk factors for complications including comorbidities, frailty, impaired immunity, or reduced ability to cough and clear secretions 4, 5

The American College of Chest Physicians recommends obtaining a chest radiograph if pneumonia is suspected based on clinical findings such as tachypnea, tachycardia, dyspnea, or abnormal lung findings 1

The British Medical Association recommends adequate fluid intake to avoid dehydration (no more than 2 liters per day) for patients with mild symptoms (cough and low-grade fever) 4, 5
The British Medical Association suggests considering honey for cough suppression in patients over 1 year of age with mild symptoms (cough and low-grade fever) 4, 5
The British Medical Association advises taking paracetamol for fever and associated symptoms in patients with mild symptoms (cough and low-grade fever) 4, 5
The Journal of Infection recommends considering empiric antibiotic therapy if bacterial infection is suspected in patients with moderate symptoms with high fever (>38.5°C) 3
The Journal of Infection suggests initiating appropriate antibiotic therapy based on likely pathogens for patients with severe symptoms or signs of pneumonia 3

The American College of Chest Physicians recommends following the same initial diagnostic algorithm but considering an expanded list of differential diagnoses based on the type and severity of immune defect in immunocompromised patients 2
The American College of Chest Physicians advises using CD4+ lymphocyte counts to guide differential diagnosis in HIV-infected patients 2
The American College of Chest Physicians suggests considering high-resolution CT scan and bronchoscopic evaluation for uncommon causes if cough persists despite appropriate evaluation and treatment 1, 2

The American College of Chest Physicians recommends not relying solely on cough characteristics for diagnosis, as they have limited diagnostic value 6, 1
The American College of Chest Physicians advises not forgetting to consider uncommon causes when cough persists despite appropriate evaluation and treatment for common causes 1, 2
The British Medical Association suggests not using antipyretics with the sole aim of reducing body temperature without addressing other symptoms 4, 5

The duration of cough can be classified as acute (< 3 weeks), subacute (3-8 weeks), or chronic (> 8 weeks) 7

For acute cough associated with common cold, the American College of Chest Physicians recommends a first-generation antihistamine/decongestant combination and naproxen can be administered to help decrease cough in this setting 8
For acute exacerbation of chronic bronchitis, a short course (10-15 days) of systemic corticosteroid therapy is recommended 9
For chronic cough, a sequential and additive treatment approach is recommended as multiple causes may be present, starting with discontinuing ACE inhibitors, counseling and assisting with smoking cessation, treating Upper Airway Cough Syndrome (UACS) with first-generation antihistamine/decongestant, and evaluating and treating for asthma with inhaled corticosteroids and bronchodilators 7, 8

For asthma-related cough, initial treatment should include inhaled bronchodilators and inhaled corticosteroids, and for refractory cases, consider adding a leukotriene receptor antagonist before escalating to systemic corticosteroids 8
For non-asthmatic eosinophilic bronchitis (NAEB), first-line treatment is inhaled corticosteroids, and if a causal allergen or occupational sensitizer is identified, avoidance is the best treatment 9

Newer generation non-sedating antihistamines should not be used for cough associated with common cold as they are ineffective 8
For chronic cough, avoid treating only one potential cause, as multiple factors often contribute 7