What are the treatment options for an upper respiratory infection with cough and nasal congestion?

Treatment of Upper Respiratory Infection with Cough and Nasal Congestion

For adults with upper respiratory infection presenting with cough and nasal congestion, use a first-generation antihistamine/decongestant combination (such as brompheniramine 6 mg plus sustained-release pseudoephedrine 120 mg twice daily) as first-line therapy for symptomatic relief. 1

Initial Management Approach

First-Line Symptomatic Treatment

• Administer a first-generation antihistamine/decongestant combination (brompheniramine/pseudoephedrine or azatadine/pseudoephedrine) for relief of cough, nasal congestion, and postnasal drip 1
• These older-generation antihistamines work primarily through their anticholinergic properties rather than histamine blockade, making them effective even in non-allergic upper respiratory infections 1
• Expect improvement within days to 2 weeks of initiating therapy 1

Additional Symptomatic Options

• Naproxen can be added to help decrease cough and provide anti-inflammatory effects 1
• Saline nasal irrigation may improve symptoms and decrease medication requirements, particularly with buffered hypertonic (3-5%) saline 1, 2
• Topical nasal decongestants (such as oxymetazoline) provide rapid relief but limit use to 3-5 consecutive days maximum to prevent rebound congestion and rhinitis medicamentosa 1, 2

What NOT to Use

• Do not use newer-generation non-sedating antihistamines (such as loratadine or terfenadine) as they are ineffective for cough and congestion in upper respiratory infections 1
• Do not use central cough suppressants (codeine or dextromethorphan) for URI-associated cough, as they have limited efficacy in this setting 1
• Do not prescribe antibiotics during the first week of symptoms, as viral rhinosinusitis is self-limited and sinus imaging abnormalities are common but do not indicate bacterial infection 1, 2

Distinguishing Viral from Bacterial Infection

Timing Considerations

• Viral rhinosinusitis typically lasts 7-10 days and accounts for most cases; 87% show sinus abnormalities on CT scan that resolve spontaneously 1, 2
• Do not diagnose bacterial sinusitis during the first week of symptoms, as clinical features and even imaging cannot reliably distinguish viral from bacterial infection during this period 1
• Approximately 25% of patients continue to have cough, postnasal drip, and throat clearing at day 14, which is part of the natural history of viral URI 1

When to Consider Antibiotics

• Reserve antibiotics for confirmed acute bacterial rhinosinusitis (ABRS) meeting specific diagnostic criteria after 7-10 days of persistent symptoms 2
• Watchful waiting without antibiotics is appropriate for uncomplicated cases with assured follow-up 1, 2
• If antibiotics are indicated: amoxicillin with or without clavulanate for 5-10 days is first-line 2

Role of Intranasal Corticosteroids

Timing and Indication

• Intranasal corticosteroids are NOT first-line therapy for acute upper respiratory infection with cough 3
• They should be initiated only after cough resolves with initial combination therapy (antihistamine/decongestant) 3
• Once cough disappears, continue intranasal corticosteroids for 3 months to prevent recurrence and maintain symptom control 3

Exception for Allergic Rhinitis

• If allergic rhinitis is the identified underlying cause, intranasal corticosteroids are appropriate as first-line therapy alongside antihistamines 1, 3

Medications with Limited or No Evidence

• Guaifenesin (expectorant): FDA-approved to loosen phlegm, but no evidence for effectiveness in URI-related cough 1, 4
• Ipratropium bromide nasal spray: May help in select cases when first-generation antihistamine/decongestant is contraindicated (glaucoma, benign prostatic hypertrophy) 1
• Mucolytics: Not consistently effective and not recommended for acute bronchitis 1

Critical Safety Considerations

• First-generation antihistamines cause sedation and anticholinergic effects but severe adverse effects are uncommon in adults 1
• Oral decongestants (pseudoephedrine) show modest efficacy with rare and mild adverse events in adults 5, 6
• Do not use cough and cold medications in children under 2 years due to risk of serious adverse events and lack of proven efficacy 7, 8

Common Pitfalls to Avoid

• Overuse of topical decongestants beyond 5 days leads to rebound congestion 1, 2
• Prescribing antibiotics prematurely (within first week) when symptoms are viral 1, 2
• Using newer antihistamines expecting the same benefit as first-generation agents 1
• Discontinuing intranasal corticosteroids too early if they are eventually started—the 3-month continuation is critical 3