Management of Acute Respiratory Illness with Cough, Headache, Fever, and Sore Throat
This presentation is most consistent with acute viral upper respiratory infection (URI) or acute bronchitis, and antibiotics are NOT indicated unless Group A Streptococcus (GAS) is confirmed by testing. 1, 2, 3
Immediate Assessment Priority
First, rule out life-threatening complications that require urgent intervention, including peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome (particularly in adolescents/young adults with severe pharyngitis). 1, 4, 3, 5 Look specifically for:
- Difficulty swallowing, drooling, neck tenderness or swelling 1
- Severe systemic toxicity or respiratory distress 5
- Cherry-red epiglottis on examination 6
Determining if Antibiotics Are Needed
The presence of cough actually argues AGAINST bacterial pharyngitis and strongly suggests viral etiology. 2, 3 This is critical because:
- Cough is specifically excluded from the Centor criteria used to assess streptococcal likelihood 2, 3
- The combination of cough with sore throat points toward viral URI or acute bronchitis rather than isolated bacterial pharyngitis 1, 2, 7
Apply the Centor criteria to assess GAS probability: 2, 3
- Fever by history (1 point)
- Tonsillar exudates (1 point) - Note: Patient has no tonsils, so this cannot be present
- Tender anterior cervical adenopathy (1 point)
- Absence of cough (1 point) - This patient FAILS this criterion
With cough present and no tonsils, this patient likely scores ≤2 points on Centor criteria, meaning:
- Do NOT test for streptococcus 2, 3
- Do NOT prescribe antibiotics 2, 3
- The likelihood of GAS is very low 1, 3
Why Antibiotics Should Be Avoided
Antibiotics provide minimal benefit even in confirmed bacterial pharyngitis - shortening symptoms by only 1-2 days - and acute bronchitis is viral in >95% of cases. 1, 8, 7 Specifically:
- For sore throat: 82% of untreated patients are symptom-free by one week regardless of antibiotic use 8
- For acute bronchitis: antibiotics reduce cough duration by only half a day while causing adverse effects including allergic reactions, nausea, vomiting, and C. difficile infection 7
- Most sore throats (>65%) are viral and resolve in less than one week 3, 9
Recommended Treatment Approach
Offer symptomatic management as first-line therapy: 1, 2, 3, 10
- Ibuprofen or acetaminophen (paracetamol) for pain and fever relief 2, 3, 10, 9
- Throat lozenges for local relief 1, 2
- First-generation antihistamines and decongestants for nasal/upper airway symptoms 2
- Cough suppressants if cough is significantly affecting quality of life 2
Reassure the patient that: 3, 9, 7
- Typical sore throat resolves in less than one week 3
- Acute bronchitis cough typically lasts 2-3 weeks but is self-limited 7
- Symptoms should improve progressively without antibiotics 9
When to Reconsider or Follow Up
Instruct the patient to return if: 10
- Fever worsens or persists beyond 3 days 10
- Pain worsens or persists beyond 10 days 10
- New symptoms develop 10
- Redness or swelling appears 10
- Symptoms persist beyond 2 weeks, which would warrant evaluation for non-infectious causes 4
Critical Pitfalls to Avoid
- Do NOT prescribe antibiotics empirically based on purulent appearance of sputum or throat - this does not distinguish bacterial from viral infection 1, 2, 7
- Do NOT apply Centor scores if cough is present - the presence of cough invalidates the scoring system for GAS assessment 2, 3
- Do NOT assume the absence of tonsils changes management - the patient can still have viral pharyngitis, and the lack of tonsils actually makes one Centor criterion impossible to meet 1
- Do NOT use antibiotics "just in case" - this contributes to antimicrobial resistance and exposes patients to unnecessary adverse effects 1, 8, 7