Management of the Common Cold
Primary Recommendation
The common cold is a self-limiting viral illness requiring only symptomatic management—never prescribe antibiotics, and use combination antihistamine-decongestant-analgesic products as first-line therapy, which provide significant symptom relief in approximately 1 out of 4 patients. 1, 2
What NOT to Do (Critical Pitfalls)
- Never prescribe antibiotics for uncomplicated common cold—they provide no benefit, cause significant adverse effects, and contribute to antimicrobial resistance 1, 2, 3
- Do not use over-the-counter cough and cold medications in children younger than 4 years due to potential harm without benefit 4, 5
- Avoid prolonged topical nasal decongestant use beyond 3-5 days to prevent rebound congestion (rhinitis medicamentosa) 2, 3
- Do not prescribe intranasal corticosteroids for acute cold symptoms—they are ineffective 2, 3
- Newer non-sedating antihistamines are ineffective; only first-generation antihistamines in combination products work 2, 3
Symptomatic Treatment Algorithm for Adults
First-Line: Combination Products
- Use combination antihistamine-decongestant-analgesic products as they provide superior relief compared to single agents, with odds ratio of treatment failure 0.47 (95% CI 0.33-0.67; number needed to treat 5.6) 2, 3
- Effective combination: first-generation antihistamine (brompheniramine) + sustained-release pseudoephedrine 2
Targeted Single-Agent Therapy
For nasal congestion:
- Oral pseudoephedrine or phenylephrine provide modest benefit 2, 3
- Topical nasal decongestants are effective but limit to 3-5 days maximum 2, 3
For rhinorrhea (runny nose):
For pain, fever, and systemic symptoms:
- NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 2, 3
- Acetaminophen may help nasal obstruction and rhinorrhea but does not improve other symptoms 2, 3
For cough:
- Dextromethorphan 60 mg provides maximum effect, though standard over-the-counter doses are likely subtherapeutic 2, 6
- Codeine has not been shown to effectively treat cold-related cough 1, 6
- Menthol inhalation provides acute but short-lived suppression 2
- Honey and lemon is recommended as simple, inexpensive home remedy 2
Adjunctive Therapies with Evidence
Zinc lozenges:
- Use ≥75 mg/day of zinc acetate or zinc gluconate formulations 2, 3
- Critical timing requirement: Must start within 24 hours of symptom onset—no benefit if symptoms already established beyond 24 hours 2, 3
- Significantly reduces cold duration when used appropriately 2, 3
- Potential side effects include bad taste and nausea 2, 3
Nasal saline irrigation:
- Provides modest symptom relief, particularly beneficial in children 2, 3
- Helps dilute secretions and facilitate elimination 2
Pediatric-Specific Management
- Acetaminophen for fever and pain 2
- Honey for cough (only in children ≥1 year old) 2, 5
- Topical ointment containing camphor, menthol, and eucalyptus oils 5
- Nasal saline irrigation 5
- Intranasal ipratropium 5
- Do not use over-the-counter cough and cold medications in children <4 years 4, 5
When to Suspect Bacterial Complication (Requires Antibiotics)
Reserve antibiotic treatment only for patients with:
- Persistent symptoms for more than 10 days without improvement 1
- Onset of severe symptoms: high fever (>39°C) AND purulent nasal discharge or facial pain lasting at least 3 consecutive days 1
- "Double sickening" pattern: worsening symptoms following initial improvement after a typical 5-day viral illness 1, 2, 7
Bacterial rhinosinusitis diagnosis requires at least 3 of 5 criteria:
- Discolored (purulent) nasal discharge 2, 7
- Severe local pain 2, 7
- Fever >38°C (100.4°F) 2, 7
- "Double sickening" pattern 2, 7
- Elevated inflammatory markers 2, 7
Important context: Only 0.5-2% of viral upper respiratory infections develop bacterial complications 2, 7
Patient Education and Expectations
- Cold symptoms typically last 7-10 days 2, 3
- Up to 25% of patients may have symptoms for 14 days—this is normal and does not indicate bacterial infection 2, 7
- Advise follow-up if symptoms worsen or exceed expected recovery time 1
- Emphasize that antibiotics will not help and may cause harm 1, 2
- Best prevention method is appropriate handwashing, as direct hand contact is the most efficient means of transmission 1
Management of Prolonged Symptoms (>10 Days)
- Symptoms persisting >10 days without improvement classify as post-viral rhinosinusitis 2, 7
- Continue symptomatic treatment with combination products 7
- Consider intranasal corticosteroids for post-viral symptoms (not acute symptoms) 7
- Do not prescribe antibiotics unless bacterial infection criteria are met 7
Red Flags Requiring Immediate Evaluation
- Hemoptysis (any amount warrants chest radiograph) 2
- Fever >38°C persisting beyond 3 days or appearing after initial improvement 2, 7
- Severe unilateral facial pain 2, 7
- Acute breathlessness 2
- Suspected foreign body inhalation (mandatory bronchoscopy referral) 2