What is the best treatment for a 75-year-old female with a week-long upper respiratory infection (URI) characterized by a productive cough and rhinorrhea?

Treatment of Upper Respiratory Infection in a 75-Year-Old Female

For this 75-year-old woman with a week-long viral upper respiratory infection presenting with productive cough and rhinorrhea, supportive care with symptom management is the appropriate treatment—antibiotics are not indicated. 1, 2

Why Antibiotics Are Not Recommended

• This presentation is consistent with a viral URI, which accounts for the vast majority of acute respiratory infections and does not benefit from antibiotic therapy 1, 2
• Bacterial infection should only be suspected when symptoms persist beyond 10 days without improvement, when severe symptoms occur (fever >39°C with purulent discharge and facial pain for ≥3 consecutive days), or when symptoms worsen after initial improvement ("double sickening") 1, 2
• At one week of symptoms, this patient has not yet met the threshold for considering bacterial rhinosinusitis 1
• The number needed to harm from antibiotics (8) exceeds the number needed to treat (18) in acute rhinosinusitis 1

Recommended Symptomatic Treatment

First-Line Therapy for Cough and Rhinorrhea

Prescribe a first-generation antihistamine/decongestant (A/D) combination as the most effective treatment for acute cough and upper airway symptoms associated with viral URI: 1, 3, 4

• Brompheniramine 12 mg plus pseudoephedrine 120 mg twice daily 3
• Alternative: Dexbrompheniramine 6 mg plus pseudoephedrine 120 mg twice daily 1, 3
• Start with once-daily dosing at bedtime for the first few days, then advance to twice daily to minimize sedation 1, 3
• Improvement typically occurs within days to 2 weeks 1, 3
• These work primarily through anticholinergic properties rather than antihistamine effects for viral URI 1, 3

Additional Symptomatic Measures

• Analgesics/antipyretics: Acetaminophen or ibuprofen for discomfort 2
• Naproxen: Can specifically help decrease cough in the common cold 1
• Saline nasal irrigation: May provide minor symptomatic relief 2
• Adequate hydration and rest 2

What NOT to Use

• Newer-generation nonsedating antihistamines (loratadine, cetirizine, fexofenadine) are ineffective for acute viral URI cough and should not be used 1
• Antibiotics are contraindicated at this stage 1, 2

Important Precautions in This 75-Year-Old Patient

Before Prescribing First-Generation Antihistamines

Screen for contraindications that are particularly relevant in elderly patients: 1, 3

• Glaucoma (anticholinergic effects can increase intraocular pressure) 1, 3
• Urinary retention or symptomatic benign prostatic hypertrophy (anticholinergic effects worsen urinary symptoms) 1, 3
• Cognitive impairment (increased sensitivity to anticholinergic effects in older adults) 3
• Hypertension (decongestant component may worsen blood pressure control) 1, 3

Alternative if Contraindications Exist

• Ipratropium bromide nasal spray can be used if first-generation antihistamines are contraindicated 1

When to Reassess for Bacterial Infection

Instruct the patient to return if: 2

• Symptoms persist beyond 10 days without improvement 1, 2
• Symptoms worsen after initial improvement 1, 2
• High fever (>39°C) develops with severe purulent discharge and facial pain lasting ≥3 consecutive days 1, 2
• Dyspnea worsens, patient stops drinking, or consciousness decreases 2

If bacterial infection is subsequently confirmed, amoxicillin would be first-line antibiotic therapy, or amoxicillin-clavulanate if risk factors for resistance exist 1, 2

Key Clinical Pitfall to Avoid

Do not interpret purulent (discolored) nasal discharge as evidence of bacterial infection—this is simply a sign of inflammation present in viral infections and does not indicate need for antibiotics 2, 5