What is the assessment and management plan for a patient with a viral upper respiratory infection (URI)?

Assessment and Plan for Viral Upper Respiratory Infection

Assessment

This is a viral upper respiratory infection (URI), a self-limiting condition that does not require antibiotics and should be managed with symptomatic care and appropriate safety netting. 1, 2

Clinical Diagnosis

• Viral URI is characterized by nasal congestion, rhinorrhea, sore throat, cough, and low-grade fever lasting less than 10 days without worsening. 1
• Discolored nasal discharge does NOT indicate bacterial infection—it reflects inflammation, not bacterial superinfection. 2
• Fewer than 2% of viral URIs are complicated by bacterial infection. 2

Rule Out Bacterial Rhinosinusitis

Do NOT diagnose bacterial rhinosinusitis unless one of these three criteria is met: 1

• Persistent symptoms ≥10 days without improvement (most common presentation)
• Severe symptoms: High fever ≥39°C (102°F) with purulent nasal discharge or facial pain for 3-4 consecutive days at illness onset
• "Double-sickening": Worsening symptoms after initial improvement at 5-6 days (new fever, headache, or increased nasal discharge)

Assess for Red Flags Requiring Urgent Evaluation

Screen for sepsis or serious illness at every encounter—ask "could this be sepsis?" 1, 2

• Temperature <35°C or ≥40°C
• Heart rate ≥125 beats/min
• Respiratory rate ≥30 breaths/min
• Blood pressure <90/60 mmHg
• Altered mental status, confusion, or drowsiness
• Cyanosis
• Inability to maintain oral intake

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Management Plan

Symptomatic Treatment (First-Line)

Provide symptomatic relief with the following measures: 2, 3

• Analgesics/antipyretics: Acetaminophen or ibuprofen for pain, fever, and inflammation 2, 3
• Adequate hydration and rest 2
• Saline nasal irrigation for minor improvement in nasal congestion 2
• Oral decongestants (if no contraindications such as hypertension or cardiac disease) for symptomatic relief 2
• Antihistamines may help with rhinorrhea, though evidence is limited 3

What NOT to Do

Do NOT prescribe antibiotics for viral URI—they are ineffective and contribute to antibiotic resistance. 2, 3

Do NOT order imaging studies (CT/MRI) for uncomplicated viral URI. 2

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Follow-Up Advice

Expected Course and Safety Netting

Educate patients on the typical duration and natural history: 1, 2

• Most viral URIs resolve within 7-10 days without treatment
• Symptoms may persist up to 3 weeks in some cases
• Cough may linger for 2-3 weeks after other symptoms resolve

Provide clear instructions on when to seek medical attention: 2

• Return immediately if:

  • Symptoms worsen rapidly or significantly at any time
  • High fever (≥39°C/102°F) develops or persists beyond 4 days
  • Severe facial pain or headache develops
  • Shortness of breath or difficulty breathing worsens
  • Patient stops drinking fluids or becomes dehydrated
  • Altered mental status or confusion occurs

• Return for reassessment if:

  • Symptoms persist beyond 10 days without improvement (consider bacterial rhinosinusitis) 1
  • "Double-sickening" occurs—initial improvement followed by worsening at 5-6 days 1
  • Symptoms persist beyond 3 weeks 2

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Worrisome Signs and Symptoms Warranting Urgent Follow-Up

Immediate Evaluation Required

The following signs indicate potential complications or serious illness requiring same-day or emergency assessment: 1, 2, 4

• Sepsis criteria: Temperature <35°C or ≥40°C, tachycardia ≥125 bpm, tachypnea ≥30 breaths/min, hypotension, altered mental status 1
• Respiratory distress: Increased work of breathing, cyanosis, oxygen saturation <92% 4
• Severe systemic symptoms: Inability to maintain oral intake, severe dehydration, persistent vomiting 2, 4
• Neurological changes: Confusion, drowsiness, severe headache with neck stiffness 1

Progression to Bacterial Infection

Consider bacterial rhinosinusitis if: 1

• Symptoms persist ≥10 days without improvement
• High fever ≥39°C with severe facial pain or purulent discharge for 3-4 days
• Worsening after initial improvement ("double-sickening")

If bacterial rhinosinusitis is suspected, reassess and consider antibiotics only if criteria are met. 1

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Special Populations at Higher Risk

Identify patients at increased risk for complications who may need closer monitoring: 2, 4

• Age >65 years with comorbidities (COPD, cardiovascular disease, diabetes)
• Recent antibiotic use within the past month
• Recent hospitalization within the past 5 days
• Immunocompromised status
• Institutionalized patients

These patients warrant lower threshold for reassessment and may benefit from earlier follow-up (48-72 hours). 2, 4

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Common Pitfalls to Avoid

• Prescribing antibiotics for viral URI (ineffective and promotes resistance) 2, 3
• Assuming purulent nasal discharge indicates bacterial infection (it does not) 2
• Ordering imaging studies for uncomplicated URI (not indicated) 2
• Failing to provide adequate safety netting advice about when to return 1
• Diagnosing bacterial rhinosinusitis before 10 days unless severe symptoms or double-sickening pattern is present 1