What is the recommended approach for managing fever in patients with viral infections such as the common cold or influenza (flu)?

Management of Fever in Viral Infections (Common Cold/Flu)

Paracetamol (acetaminophen) is the first-line antipyretic and analgesic treatment for managing fever and associated symptoms in patients with viral infections such as the common cold or influenza. 1

First-Line Treatment Approach

• Paracetamol should be administered to alleviate fever and associated symptoms like myalgia and headache, not solely to reduce body temperature 1
• The standard adult dosage is 650mg every 4-6 hours as needed for symptomatic relief 1, 2
• Treatment should continue only while symptoms of fever and discomfort persist 1
• For children under 16 years, aspirin is contraindicated due to the risk of Reye's syndrome 3, 1

Comprehensive Symptom Management

• Adequate hydration (up to 2 liters per day) is essential but avoid overhydration 1, 4
• Rest is recommended until symptoms improve 1
• Consider short-term use of topical decongestants, throat lozenges, or saline nose drops for nasal congestion and sore throat 1
• For children over 1 year with cough, honey can be considered as a simple remedy 1

When Paracetamol Is Insufficient

• If fever persists above 38°C after paracetamol administration, consider adding an NSAID such as ibuprofen 5
• NSAIDs like ibuprofen should be used with caution in patients with certain comorbidities (renal impairment, history of peptic ulcer disease, etc.) 1
• Physical cooling methods such as tepid sponging may be considered for persistent high fever 5

Antiviral Considerations

• Oseltamivir should be considered for patients who have:
  • An acute influenza-like illness
  • Fever (>38°C in adults, >38.5°C in children)
  • Been symptomatic for two days or less 3, 1
• The standard adult dosage for oseltamivir is 75mg every 12 hours for five days (dose reduced by 50% if creatinine clearance is <30 ml/min) 3, 6
• Patients who cannot mount an adequate febrile response (immunocompromised or elderly) may still benefit from antiviral treatment despite lack of documented fever 3

Antibiotic Use

• Previously well adults with acute bronchitis complicating influenza do not routinely require antibiotics 3, 4
• Consider antibiotics only if:
  • Symptoms are worsening (recrudescent fever or increasing dyspnea)
  • Patient is at high risk of complications
  • There are signs of bacterial infection 3

When to Seek Medical Attention

• Patients should be advised to seek medical attention if they develop:
  • Shortness of breath at rest or with minimal activity
  • Painful or difficult breathing
  • Coughing up bloody sputum
  • Drowsiness, disorientation, or confusion
  • Fever persisting for 4-5 days without improvement
  • Initial improvement followed by recurrence of high fever 1, 4

Special Considerations

• The evidence for routine antipyretic use is mixed - some studies show improved outcomes while others suggest fever may have beneficial effects during infection 7
• Over-the-counter cold and flu medications are generally safe and effective for treating COVID-19 symptoms as well, as the innate immune response mechanisms are similar 8
• In comparative studies, both paracetamol and aspirin have shown similar efficacy in reducing fever, but paracetamol has a better safety profile 2, 9

Monitoring

• Monitor vital signs including temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation in patients with significant symptoms 4
• Consider hospital admission if the patient has two or more unstable clinical factors: temperature >37.8°C, heart rate >100/min, respiratory rate >24/min, systolic blood pressure <90 mmHg, or oxygen saturation <90% 3, 4