Epidemiology, clinical presentation, management, and prognosis of prolonged cough in adults in the outpatient setting
Marchello, Christian S
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Background: Approximately 20 million visits to an ambulatory physician per year are due to the primary complaint of a cough. Observed duration for an acute cough in the literature (15 to 28 days) is longer than patient expectations (7 to 9 days). Examining the clinical presentation and management decisions for the subset of patients with an uncomplicated acute cough of at least a week may help reduce the ordering of chest x-rays (CXR) and the overprescribing of antibiotics, steroids, and cough suppressants. Methods: A systematic review and meta-analysis of clinical decision rules (CDR) for low yield criteria of community-acquired pneumonia (CAP). In addition, adults 18 years or older presenting with a cough as their main or chief complaint were recruited for a mixed cross-sectional and prospective observational study. Patients were surveyed for demographics, signs and symptoms, and clinicians documented their management decisions. Participants recorded duration and severity of symptoms for up to 14 days after enrollment. Results: Normal vital signs combined with a normal pulmonary exam performed well as a CDR to rule out CAP (LR- 0.10, 95% CI 0.07-0.13). A total of 125 patients enrolled over the study period, 118 (94%) received an antibiotic, 39 (31%) CXR, 87 (70%) a systemic corticosteroid, and 97 (78%) a cough suppressant. A normal chest exam by the clinician is significantly associated with a longer duration of a cough (LR+ 2.11, 95% CI: 1.07-4.16 and LR- 0.49, 0.32-0.75). Dyspnea was significantly associated with ordering a CXR (aOR 3.01, 95% CI 1.21-7.49). Clinician recorded crackles significantly decreased the likelihood of a systemic corticosteroid prescription (aOR 0.27, 95% 0.09-0.82). Increasing age was significantly associated with an increased likelihood of being prescribed a cough suppressant (aOR 1.04 per additional year of age, 95% CI 1.01-1.07). Conclusions: A combination of normal vital signs and a normal pulmonary exam in adults with acute respiratory infection can be used as low yield criteria for CAP. Chest x-rays, antibiotics, systemic corticosteroids and cough suppressants are commonly used in patients with uncomplicated acute cough of at least seven days duration in the urgent care setting.