Postinfectious Cough

ACCP Evidence-Based Clinical Practice Guidelines

Sidney S. Braman, MD, FCCP

Background: Patients who complain of a persistent cough lasting > 3 weeks after experiencing
the acute symptoms of an upper respiratory tract infection may have a postinfectious cough.
Such patients are considered to have a subacute cough because the condition lasts for no > 8
weeks. The chest radiograph findings are normal, thus ruling out pneumonia, and the cough
eventually resolves, usually on its own. The purpose of this review is to present the evidence
for the diagnosis and treatment of postinfectious cough, including the most virulent form
caused by Bordetella pertussis infection, and make recommendations that will be useful for
clinical practice.
Methods: Recommendations for this section of the guideline were obtained from data using
a National Library of Medicine (PubMed) search dating back to 1950, which was performed
in August 2004, of the literature published in the English language. The search was limited
to human studies, using the search terms “cough,” “postinfectious cough,” “postviral cough,”
“Bordetella pertussis,” “pertussis infection,” and “whooping cough.”
Results: The pathogenesis of the postinfectious cough is not known, but it is thought to be due
to the extensive inflammation and disruption of upper and/or lower airway epithelial
integrity. When postinfectious cough emanates from the lower airway, this is often associated
with the accumulation of an excessive amount of mucus hypersecretion and/or transient
airway and cough receptor hyperresponsiveness; all may contribute to the subacute cough. In
these patients, the optimal treatment is not known. Except for bacterial sinusitis or early on
in a B pertussis infection, therapy with antibiotics has no role, as the cause is not bacterial
infection. The use of inhaled ipratropium may be helpful. Other causes of postinfectious
cough are persistent inflammation of the nose and paranasal sinuses, which leads to an upper
airway cough syndrome (previously referred to as postnasal drip syndrome), and gastroesoph-
ageal reflux disease, which may be a complication of the vigorous coughing. One type of
postinfectious cough that is particularly virulent is that caused by B pertussis infection. When
the cough is accompanied by paroxysms of coughing, posttussive vomiting, and/or an
inspiratory whooping sound, the diagnosis of a B pertussis infection should be made unless
another diagnosis is proven. This infection is highly contagious but responds to antibiotic
coverage with an oral macrolide when administered early in the course of the disease. A safe
and effective vaccine to prevent B pertussis is now available for adults as well as children. It
is recommended according to CDC guidelines.
Conclusions: In patients who have a cough lasting from 3 to 8 weeks with normal chest
radiograph findings, consider the diagnosis of postinfectious cough. In most patients, a
specific etiologic agent will not be identified, and empiric therapy may be helpful. A high
degree of suspicion for cough due to B pertussis infection will lead to earlier diagnosis,
patient isolation, and antibiotic treatment. (CHEST 2006; 129:138S–146S)

Key words: Bordetella pertussis; pertussis infection; postinfectious cough; postviral cough

Abbreviations: CDC ⫽ Centers for Disease Control; FHA ⫽ filamentous hemagglutinin; PCR ⫽ polymerase
chain reaction; PT ⫽ pertussis toxin; UACS ⫽ upper airway cough syndrome

P lowing
atients may complain of a persistent cough fol-
symptoms of an upper respiratory tract
longer considered to be an acute cough. Instead, it is
considered to be in the category of subacute cough.
infection; when the cough lasts for ⬎ 3 weeks, it is no Some authors1– 4 have labeled the cough following a

138S Diagnosis and Management of Cough: ACCP Guidelines

viral or virus-like infection (eg, with Mycoplasma or
Chlamydophila) as a postinfectious cough. In the
definition of postinfectious cough are the following
elements: the cough lasts no ⬎ 8 weeks; the chest
radiograph findings are negative, ruling out pneumo-
nia; and the cough eventually resolves, usually on its
own. Hence, the subacute postinfectious cough is
distinguished from the chronic cough by the dura-
tion of coughing, with the chronic cough lasting for
at least 8 weeks and in most instances for many
months and even years. Recommendations for this
section of the guideline were obtained from data
using a National Library of Medicine (PubMed)
search dating back to 1950, which was performed in
August 2004, of the literature published in the
English language. The search was limited to human
studies, using the search terms “cough,” “postinfec-
tious cough,” “postviral cough,” “Bordetella pertus-
sis,” “pertussis infection,” and “whooping cough.”
Postinfectious Cough
Pathogenesis
While the pathogenesis of the postinfectious
cough is not known, it has been thought to be due to
the extensive disruption of epithelial integrity and
widespread airway inflammation of the upper and/or
lower airways with or without transient airway hy-
perresponsiveness.5– 8 Bronchoscopy and biopsy per-
formed on patients with uncomplicated influenza A
infection, for example, reveals extensive desquama-
tion of epithelial cells to the level of the basement
membrane.9 The percentage of lymphocytes and
neutrophils in BAL fluid is high, and bronchial
biopsy material shows a lymphocytic bronchitis.9
Although bronchial hyperresponsiveness is present
in some patients with postinfectious cough, eosino-
philic inflammation, which is typical of asthma, is
absent.10 Despite the presence of symptomatic
heightened coughing, cough receptor sensitivity to
capsaicin and tartaric acid inhalation challenge has
not been found to be heightened in the acute and
convalescent phases of postinfectious cough due to
Mycoplasma pneumoniae.11 On the other hand, with
upper respiratory infections of undetermined cause
that produce a persistent cough, it has been shown
that there is an increased sensitivity to inhaled
capsaicin during the acute phase of the illness. When
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Sidney S. Braman, MD, FCCP, Division of
Pulmonary and Critical Care Medicine, Rhode Island Hospital,
595 Eddy St, Providence, RI 02903; e-mail: sidney_braman@
brown.edu
www.chestjournal.org
tested during convalescence at 4 weeks and beyond,
cough sensitivity returns to baseline.12
Therefore, transient inflammation of the lower
airways is likely to be important in the pathogenesis
in some patients with postinfectious cough. This
speculation is based on the fact that cough may be
induced by the heightened responsiveness of the
cough receptors, by bronchial hyperresponsiveness
as is seen in cough-variant asthma, or by impaired
mucociliary clearance from the disruption of the
epithelial lining of the airways. Because airway in-
flammation causes mucus hypersecretion, retained
secretions resulting from excessive mucus produc-
tion and decreased clearance may be another impor-
tant mechanism of cough. Additionally, persistent
inflammation of the upper airway, particularly the
nose and paranasal sinuses, can be the cause of or
can contribute to postinfectious cough. When secre-
tions drain into the hypopharynx and larynx or when
there is inflammation of the upper airway, cough
receptors can be stimulated, and this may persist for
weeks or longer following an upper respiratory in-
fection.13 Another mechanism to consider in postin-
fectious cough is gastroesophageal reflux. Although
viral infection itself does not cause gastroesophageal
reflux disease, the vigorous coughing that follows may
induce or aggravate preexisting reflux disease because
of the high abdominal pressures that are generated.
Patients with the subacute postinfectious cough are
therefore similar to those with chronic cough. The
pathogenesis is frequently multifactorial.14,15
Recommendations
1. When a patient complains of cough that
has been present following symptoms of an
acute respiratory infection for at least 3 weeks,
but not more than 8 weeks, consider a diagnosis
of postinfectious cough. Quality of evidence, ex-
pert opinion; net benefit, intermediate; strength of
recommendation, E/B
2. In patients with subacute postinfectious
cough, because there are multiple pathogenetic
factors that may contribute to the cause of
cough (including postviral airway inflammation
with its attendant complications such as bron-
chial hyperresponsiveness, mucus hypersecre-
tion and impaired mucociliary clearance, upper
airway cough syndrome [UACS], asthma, and
gastroesophageal reflux disease), judge which
factors are most likely provoking cough before
considering therapy. Quality of evidence, expert
opinion; net benefit, intermediate; strength of rec-
ommendation, E/B
CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 139S
Prevalence
In adults, postinfectious cough has been reported
with a variable frequency. In retrospective stud-
ies1,2,4,16 of unselected patients with a history of
upper respiratory tract infection, the frequency has
ranged from 11 to 25%. During outbreaks of obvious
infection with M pneumoniae and Bordetella pertus-
sis, the frequency of postinfectious cough increases
to 25 to 50% in selected series.17 In prospective
studies14,18 –20 of unselected patients, many of whom
had a history of upper respiratory tract infection,
postinfectious cough was not diagnosed. The expla-
nation for this low frequency in the latter studies is
likely related to differences in the study populations
reported and to the fact that most patients in these
series had experienced the cough for many months
or years.
In children, the specific infection causing the
postinfectious cough in most cases remains un-
identified. Respiratory viruses (particularly respi-
ratory syncytial virus, influenza, parainfluenza, and
adenovirus), M pneumoniae, Chlamydophila pneu-
moniae strain TWAR, Moraxella catarrhalis, and B
pertussis have all been implicated.21–28 In the
general population, there is an average of 2.2 viral
respiratory infections per person per year, but in
children this number is considerably higher.29
Children under 5 years of age have 3.8 to 5
infections per person per year. Those children in
daycare are especially at risk.25 Back-to-back in-
fections, which are particularly common in winter
months, can frequently result in a chronic cough.
Similarly, coinfection with more than one of these
organisms can occur, and this can increase the
period of paroxysmal coughing.28 Prolonged cough
after Chlamydophila and Mycoplasma infections
may also be quite common. A duration of cough of
⬎ 21 days in young children following pneumonia
with these organisms has been found in 57% and
28% of patients, respectively.30
Diagnosis
The diagnosis of postinfectious cough is clinical
and one of exclusion. A careful medical history,
including knowledge of the medical history of con-
tacts, and sometimes the physical examination may
provide clues to the diagnosis. As the cough is usually
self-limited, it will resolve in time. When M pneu-
moniae infection is suspected, as in school-age chil-
dren or young adults, particularly in military person-
nel, in late summer or fall, acute and convalescent-
specific serologic studies may help to confirm the
diagnosis.
140S
Recommendation
3. In children and adult patients with cough
following an acute respiratory tract infection, if
cough has persisted for > 8 weeks, consider
diagnoses other than postinfectious cough.
Quality of evidence, low; net benefit, intermediate;
strength of recommendation, C
Treatment
The postinfectious cough is self-limited and will
usually resolve in time. Therapy with antibiotics has
no role in the treatment of postinfectious cough, as
there is no evidence that bacterial infection plays a
role. Based on the speculation that the postinfectious
cough is due to inflammation, some authors in
uncontrolled studies have successfully treated the
cough with a brief course of corticosteroids starting
with 30 to 40 mg of prednisone (or equivalent) in the
morning, tapering to zero over 2 to 3 weeks.1 This
regimen may be tried in those patients whose coughs
become protracted and persistently troublesome.
The organisms that are associated with postinfectious
cough cause considerable transmigration of neutro-
phils across bronchial epithelial cells,31 and sputum
analysis may show an increase in lymphocytes fol-
lowed by an increase in neutrophils.32 M pneumoniae
causes intense airway neutrophil inflammation and
bronchial hyperresponsiveness in animal models,
and both can be suppressed by inhaled fluticasone
propionate.33,34 Clinical data to support this ap-
proach in humans are lacking. In one small con-
trolled trial,35 ipratropium bromide was shown to
attenuate postinfectious cough. There have been no
clinical trials conducted on the effect of centrally
acting antitussive agents on postinfectious cough.
Failure to respond to treatment should alert one to
consider UACS due to rhinosinus diseases, asthma,
or gastroesophageal reflux disease as the cause of the
cough.
Recommendations
4. For adult patients with postinfectious
cough, not due to bacterial sinusitis or early on
in a Bordetella pertussis infection, while the
optimal treatment is not known:
4a. Therapy with antibiotics has no role, as
the cause is not bacterial infection. Level of
evidence, expert opinion; net benefit, none; grade of
evidence, I
4b. Consider a trial of inhaled ipratropium as
it may attenuate the cough. Level of evidence,
fair; net benefit, intermediate; grade of evidence, B
4c. In patients with postinfectious cough,
Diagnosis and Management of Cough: ACCP Guidelines
when the cough adversely affects the patient’s
quality of life and when cough persists despite
use of inhaled ipratropium, consider the use of
inhaled corticosteroids. Level of evidence, expert
opinion; net benefit, intermediate; grade of evi-
dence, E/B
4d. For severe paroxysms of postinfectious
cough, consider prescribing 30 to 40 mg of
prednisone per day for a short, finite period of
time when other common causes of cough (eg,
UACS due to rhinosinus diseases, asthma, or
gastroesophageal reflux disease) have been
ruled out. Level of evidence, low; net benefit,
intermediate; grade of evidence, C
4e. Central acting antitussive agents such as
codeine and dextromethorphan should be con-
sidered when other measures fail. Level of evi-
dence, expert opinion; net benefit, intermediate;
grade of evidence, E/B
B PERTUSSIS Infection and Cough
One type of postinfectious cough that is particu-
larly virulent is that caused by B pertussis infection.
Recommendations for this section of the review
relating to Bordetella infection and cough were
made using data obtained from a National Library of
Medicine (PubMed) search dating back to 1950,
which was performed in August 2004, of the litera-
ture published in the English language. The search
was limited to human studies, using the search terms
“cough,” “Bordetella pertussis,” “Pertussis infection,”
and “whooping cough.”
Prevalence
B pertussis is a small pleomorphic Gram-negative
coccobacillus that has been increasingly recognized
as a cause of persistent cough in adolescents and
adults. Because it leads to severe paroxysms of
coughing with frequent complications, is highly con-
tagious in children and adults, and responds to
appropriate antibiotic coverage when administered
early in the course of the disease, it is considered
separately from other causes of postinfectious cough.
The organisms are inhaled into the respiratory sys-
tem by aerosol droplets, where they adhere to and
invade the ciliated epithelial cells.36 Unlike other
causes of postinfectious cough, pertussis infection or
whooping cough can result in prolonged episodes of
coughing. In fact, postinfectious cough has been
nicknamed the hundred day cough.37 The organism
is highly contagious as one active case can infect 70
to 100% of household contacts and 50 to 80% of
school contacts.38 The incidence of pertussis infec-
tion, or whooping cough, declined dramatically after
www.chestjournal.org
the introduction of the whole-cell pertussis vaccine
in the 1940s. Since the early 1980s, despite wide-
spread vaccination, there has been an increase in
incidence over all age groups,39 because complete
immunization is not protective for all children, many
children are incompletely immunized, and immunity
wanes in most cases. The increase in incidence,
however, has been particularly evident in adoles-
cents and adults, with the greatest increase occurring
in patients between the ages of 10 and 19 years.40
This likely occurs because immunity from immuni-
zation wanes in the decade that follows the most
recent immunization41,42 and also because the num-
ber of adults who had immunity from natural infec-
tion in the prevaccine era is progressively decreasing.
The annual incidence rate still remains highest
among infants ⬍ 1 year of age, and in the majority of
such children adults are the source of infection.43– 46
Bordetella parapertussis has been shown to cause a
disease similar to whooping cough but of shorter
duration, possibly because it does not produce the
pertussis toxin (PT), the principle agent responsible
for severe coughing.47 Immunization with standard
pertussis vaccines has not provided protection from
B parapertussis,28 while modest protection has been
seen with the newer acellular vaccines.48
Clinical Presentation
Pertussis infection can present in a variety of
settings; it may be an important cause of cough in
college students,49 in military personnel,24 in refer-
rals to a pulmonary specialist,16,50 in patients seeking
emergency department care,51 in those seen in the
primary care setting,51–54 in health-care workers,55
and in the elderly.56 Unfortunately, pertussis is not
considered in the differential diagnosis of chronic
cough by many practitioners.57 However, in a Cana-
dian multicenter prospective study,54 pertussis infec-
tion was confirmed in 19.9% of adolescents and
adults who met the criteria for postinfectious cough.
The classic case of pertussis has been well-described.
After an incubation period of 1 to 3 weeks, a 2-week
virus-like illness ensues, and during this catarrhal
phase symptoms of conjunctivitis, rhinorrhea, fever,
malaise, and, later, cough occur. Leukocytosis and
lymphocytosis, which are thought to be typical of a
pertussis infection, frequently are not seen.16,51,58
The next phase, the paroxysmal phase, is character-
ized by worsening cough, often with the character-
istic whooping sound, which consists of a series of
expiratory bursts followed by a sudden loud inspira-
tory sound. In children ⬍ 2 years of age, vomiting or
apnea is more commonly seen than the typical
whooping sound.25 Adults may complain of shortness
of breath and a tingling sensation in the throat, and
CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 141S
posttussive emesis is common. The whooping sound
is also usually absent in adults. The cough tends to be
spasmodic, and occurs more frequently at night and
after exposure to cold air; it lasts usually 4 to 6 weeks
but can persist for much longer during the convales-
cent phase. The duration and frequency of symp-
toms vary widely but are more severe in females and
in nonimmunized individuals.53 In adults and adoles-
cents, it is common to have a nondistinct protracted
cough as the only manifestation of pertussis infec-
tion.58 And many individuals never become symp-
tomatic. Clinical and serologic surveys56 of elderly
subjects living independently have shown that be-
tween 3.3% and 8% have pertussis infections each
year; yet, only 37.5 to 50% of such individuals are
symptomatic.
Diagnosis
Both probable and confirmed cases of pertussis
infection should be reported to the public health
authorities. A clinical case is defined as an acute
illness with a cough that is persistent for ⬎ 2 weeks
and is associated with posttussive vomiting, the
typical whooping sound, or severe paroxysms.59 A
confirmed case is one in which B pertussis has been
isolated or is a clinical case that has been confirmed
by polymerase chain reaction (PCR) or epidemio-
logic linkage to a confirmed case.59 A probable case
meets the clinical case definition without laboratory
or epidemiologic confirmation.59 The most reliable
way to make the diagnosis is by detection of the
organism from nasopharynx secretions. However,
culturing the organism requires enriched media, and
its sensitivity has been reported to be as low as 25 to
50%. PCR is a rapid and highly specific test for
Bordetella spp and has a sensitivity as high as 80 to
100%.60 Although widely used in the United States,
PCR assays have not been standardized. A number
of serologic studies are available, including IgG and
IgA titers of the antibody to PT, filamentous hem-
agglutinin (FHA), pertactin, and fimbriae. The most
generally accepted serologic criterion for diagnosis is
the enzyme-linked immunosorbent assay test to
demonstrate a significant increase in IgG serum
antibody against PT. Paired sera are necessary as
nonrising titers may represent past infection or
previous immunization. The first serum sample
should be taken within 2 weeks of the onset of cough,
and the second should be taken 3 to 4 weeks later.
The reported specificities and sensitivities of this test
are 99% and 63%, respectively, when used for
documenting community outbreaks of pertussis in-
fection.61 Although widely used in epidemiologic
surveys, paired sera titers have shown less usefulness
in the clinical evaluation of cough because patients
142S
often delay seeking medical care and paired samples
cannot be obtained.62 While a single serum specimen
that shows high titers when compared to reference
values is highly suggestive of a recent pertussis
infection when there is a compatible clinical picture,
no serologic method for diagnosis has been validated
and approved for diagnostic use in the United States.
Recommendations
5. When a patient has a cough lasting for > 2
weeks without another apparent cause and it is
accompanied by paroxysms of coughing, post-
tussive vomiting, and/or an inspiratory whoop-
ing sound, the diagnosis of a B pertussis infec-
tion should be made unless another diagnosis is
proven. Level of evidence, low; net benefit, sub-
stantial; grade of evidence, B
6a. For all patients who are suspected of
having whooping cough, to make a definitive
diagnosis order a nasopharyngeal aspirate or
polymer (Dacron; INVISTA; Wichita, KS) swab
of the nasopharynx for culture to confirm the
presence of B pertussis. Isolation of the bacteria
is the only certain way to make the diagnosis.
Level of evidence, low; net benefit, substantial; grade of
evidence, B
6b. PCR confirmation is available but is not
recommended as there is no universally ac-
cepted, validated technique for routine clinical
testing. Level of evidence, low; net benefit, conflict-
ing; grade of evidence, I
7. In patients with suspected pertussis infec-
tion, to make a presumptive diagnosis of this
infection, order paired acute and convalescent
sera in a reference laboratory. A fourfold in-
crease in IgG or IgA antibodies to PT or FHA is
consistent with the presence of a recent B
pertussis infection. Level of evidence, low; net
benefit, intermediate; grade of evidence, C
8. A confirmed diagnosis of pertussis infec-
tion should be made when a patient with cough
has B pertussis isolated from a nasopharyngeal
culture or has a compatible clinical picture with
an epidemiologic linkage to a confirmed case.
Level of evidence, low; net benefit, substantial; grade of
evidence, B
Treatment
In the case of proven or presumed pertussis
infection, prospective clinical trials have shown that
treatment with erythromycin (or trimethoprim/sulfa-
methoxazole when a macrolide cannot be given) is
necessary; the recommended dose is 40 to 50 mg/
kg/d in children and 1 to 2 g per day in adults for 2
Diagnosis and Management of Cough: ACCP Guidelines
weeks.63 Therapy should begin as soon as the disease
is suspected and should not be delayed until confir-
mation of the diagnosis, as early therapy during the
catarrhal phase (ie, the first 2 weeks) will rapidly
clear B pertussis from the nasopharynx64 – 66 and
decrease the coughing paroxysms and other compli-
cations.64,67–70 Patients with active cases should be
isolated at home and away from work or school for 5
days after therapy with antibiotics is started. There is
some evidence70 that therapy given in the paroxys-
mal phase may be effective, but it is usually of
limited benefit. Erythromycin resistance has been
reported but is quite rare (⬍ 1%). Newer macrolides
such as clarithromycin and azithromycin are also
active against B pertussis and have a better side-
effect profile. Until the past few years, only small
clinical trials65,71,72 have been available to support
their use. In a large multicenter randomized trial,73
azithromycin was found to be as effective as eryth-
romycin estolate in the treatment of pertussis in
children with much better compliance because of a
better side-effect profile. The newer fluoroquinolo-
nes also show good in vitro activities against B
pertussis, but there are no clinical trials to support
their use. Prophylaxis for exposed persons has been
found to be effective in decreasing the severity and
transmission of the disease to others if therapy is
begun early (ie, within the first 2 weeks of the
infection).63
The benefits of adding long-acting ␤-agonists,
antihistamines, corticosteroids, and pertussis Ig have
been studied in pertussis infection. No significant
benefit has been found with any of these interven-
tions in controlling the paroxysms of coughing.74
Results of trials in adults and children using acellular
pertussis vaccines rather than whole cell vaccines
suggest that in the future, pertussis may be safely and
effectively prevented in all age groups. In the past
pertussis vaccines have been approved only for chil-
dren under age seven and a series of 5 doses
(coupled with diphtheria and tetanus toxoid) is rec-
ommended before the 7th birthday. Acellular vac-
cines are currently approved for children in this age
group.75 Two adult formulations of the new acellular
vaccine are now licensed in North America (2005
approval in the US) and are combined with diphthe-
ria and tetanus toxoid (dTap). The rapid rise in the
number and proportion of cases of pertussis among
adolescents and adults in recent years called for a
study in this age group. A large multicentered ran-
domized, controlled, double-blind trial of acellular
pertussis vaccine in a population aged 15– 65 years
was funded by the National Institute of Allergy and
Infectious Diseases and reported in 2005.76 The
vaccine was highly effective, with a protection rate of
92% (95% confidence interval, 32–99%), and proved
www.chestjournal.org
to be very safe in this age group. Because the rate of
pertussis in the nonimmunized population in this
study was 370 cases per 100,000, the potential for
case rate reduction is enormous. In 2005, the US
Advisory committee on Immunization Practices en-
dorsed the use of a single dose of dTap vaccine in
adolescents aged 11–18 years (www.cdc.gov/nip/pr/
pr_tdap_jun2005.htm). A similar recommendation
has just been announced for adults up to 65 years of
age.
Recommendations
9. Children and adult patients with con-
firmed or probable whooping cough should
receive a macrolide antibiotic and should be
isolated for 5 days from the start of treatment
because early treatment within the first few
weeks will diminish the coughing paroxysms
and prevent spread of the disease; treatment
beyond this period may be offered but it is
unlikely the patient will respond. Level of evi-
dence, good; net benefit, substantial; grade of evi-
dence, A
10. Long-acting ␤-agonists, antihistamines,
corticosteroids, and pertussis Ig should not be
offered to patients with whooping cough be-
cause there is no evidence that they benefit
these patients. Level of evidence, good; net benefit,
none; grade of evidence, D
11. All children should receive prevention
against pertussis infection as part of a complete
diphtheria, tetanus, acellular pertussis (DTap)
primary vaccination series. This should be fol-
lowed by a single dose DTap booster vaccina-
tion early in adolescence. Level of evidence, good;
net benefit, substantial; grade of evidence, A
12. For all adults up to the age of 65, vacci-
nation with the stronger formulation of TDap
vaccine should be administered according to
CDC guidelines. Level of evidence, expert opinion;
net benefit, substantial; grade of evidence, E/A
Summary of Recommendations
1. When a patient complains of cough
that has been present following symptoms
of an acute respiratory infection for at least
3 weeks, but not more than 8 weeks, con-
sider a diagnosis of postinfectious cough.
Quality of evidence, expert opinion; net benefit,
intermediate; strength of recommendation, E/B
2. In patients with subacute postinfec-
tious cough, because there are multiple
CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 143S
 pathogenetic factors that may contribute to
the cause of cough (including postviral air-
way inflammation with its attendant compli-
cations such as bronchial hyperresponsive-
ness, mucus hypersecretion and impaired
mucociliary clearance, upper airway cough
syndrome [UACS], asthma, and gastro-
esophageal reflux disease), judge which fac-
tors are most likely provoking cough before
considering therapy. Quality of evidence, ex-
pert opinion; net benefit, intermediate; strength
of recommendation, E/B
3. In children and adult patients with
cough following an acute respiratory tract
infection, if cough has persisted for > 8
weeks, consider diagnoses other than
postinfectious cough. Quality of evidence, low;
net benefit, intermediate; strength of recom-
mendation, C
4. For adult patients with postinfectious
cough, not due to bacterial sinusitis or early
on in a Bordetella pertussis infection, while
the optimal treatment is not known:
4a. Therapy with antibiotics has no role,
as the cause is not bacterial infection. Level
of evidence, expert opinion; net benefit, none;
grade of evidence, I
4b. Consider a trial of inhaled ipratro-
pium as it may attenuate the cough. Level of
evidence, fair; net benefit, intermediate; grade
of evidence, B
4c. In patients with postinfectious cough,
when the cough adversely affects the pa-
tient’s quality of life and when cough per-
sists despite use of inhaled ipratropium,
consider the use of inhaled corticosteroids.
Level of evidence, expert opinion; net benefit,
intermediate; grade of evidence, E/B
4d. For severe paroxysms of postinfec-
tious cough, consider prescribing 30 to 40
mg of prednisone per day for a short, finite
period of time when other common causes
of cough (eg, UACS due to rhinosinus dis-
eases, asthma, or gastroesophageal reflux
disease) have been ruled out. Level of evi-
dence, low; net benefit, intermediate; grade of
evidence, C
4e. Central acting antitussive agents such
as codeine and dextromethorphan should
be considered when other measures fail.
Level of evidence, expert opinion; net benefit,
intermediate; grade of evidence, E/B
5. When a patient has a cough lasting for
> 2 weeks without another apparent cause
144S
and it is accompanied by paroxysms of
coughing, posttussive vomiting, and/or an
inspiratory whooping sound, the diagnosis
of a B pertussis infection should be made
unless another diagnosis is proven. Level of
evidence, low; net benefit, substantial; grade of
evidence, B
6a. For all patients who are suspected
of having whooping cough, to make a
definitive diagnosis order a nasopharyn-
geal aspirate or polymer (Dacron; IN-
VISTA; Wichita, KS) swab of the nasophar-
ynx for culture to confirm the presence of
B pertussis. Isolation of the bacteria is the
only certain way to make the diagnosis.
Level of evidence, low; net benefit, substan-
tial; grade of evidence, B
6b. PCR confirmation is available but is
not recommended as there is no universally
accepted, validated technique for routine
clinical testing. Level of evidence, low; net
benefit, conflicting; grade of evidence, I
7. In patients with suspected pertussis
infection, to make a presumptive diagnosis
of this infection, order paired acute and
convalescent sera in a reference laboratory.
A fourfold increase in IgG or IgA antibodies
to PT or FHA is consistent with the presence
of a recent B pertussis infection. Level of
evidence, low; net benefit, intermediate; grade
of evidence, C
8. A confirmed diagnosis of pertussis in-
fection should be made when a patient with
cough has B pertussis isolated from a naso-
pharyngeal culture or has a compatible clin-
ical picture with an epidemiologic linkage
to a confirmed case. Level of evidence, low;
net benefit, substantial; grade of evidence, B
9. Children and adult patients with con-
firmed or probable whooping cough should
receive a macrolide antibiotic and should be
isolated for 5 days from the start of treat-
ment because early treatment within the
first few weeks will diminish the coughing
paroxysms and prevent spread of the disease;
treatment beyond this period may be offered
but it is unlikely the patient will respond.
Level of evidence, good; net benefit, substantial;
grade of evidence, A
10. Long-acting ␤-agonists, antihista-
mines, corticosteroids, and pertussis Ig
should not be offered to patients with
whooping cough because there is no evi-
dence that they benefit these patients. Level
Diagnosis and Management of Cough: ACCP Guidelines

of evidence, good; net benefit, none; grade of
evidence, D
11. All children should receive preven-
tion against pertussis infection as part of a
complete diphtheria, tetanus, acellular per-
tussis (DTap) primary vaccination series.
This should be followed by a single dose
DTap booster vaccination early in adoles-
cence. Level of evidence, good; net benefit,
substantial; grade of evidence, A
12. For all adults up to the age of 65,
vaccination with the stronger formulation of
TDap vaccine should be administered ac-
cording to CDC guidelines. Level of evi-
dence, expert opinion; net benefit, substantial;
grade of evidence, E/A
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