What are the recommended medications for managing sore throat and cough in an uncomplicated systemic viral infection?

Management of Sore Throat and Cough in Uncomplicated Viral Infections

For uncomplicated viral respiratory infections causing sore throat and cough, symptomatic treatment with analgesics (ibuprofen or acetaminophen) is the primary recommendation, while antibiotics should be avoided entirely. 1, 2

Sore Throat Management

First-Line Symptomatic Treatment

• Analgesics or antipyretics (ibuprofen or acetaminophen) should be given for pain relief 1, 3
• Nasal saline irrigation may provide symptomatic relief with minimal risk of adverse effects 1
• Topical intranasal corticosteroids may modestly reduce facial pain and nasal congestion (66% improved with placebo vs 73% with steroids at 14-21 days), though the benefit is small and should be based on patient preference 1

Additional Symptomatic Options

• Oral decongestants may provide relief but should be avoided in patients with hypertension or anxiety 1
• Topical decongestants should not be used for more than 3-5 days to avoid rebound congestion 1
• Oral antihistamines may help with excessive secretions and sneezing, though clinical evidence is lacking 1

What NOT to Do

• Do not prescribe antibiotics for viral sore throat - most cases (>80%) are viral and resolve within 7 days without antibiotics 3, 4, 5
• Antibiotics provide minimal benefit (reducing symptoms by only 1-2 days) while causing significant adverse effects 1

Cough Management

Bronchodilator Therapy

• Albuterol (beta-2 agonist) is the most effective treatment for cough in acute bronchitis, with approximately 50% fewer patients reporting cough after 7 days of treatment 1
• This efficacy makes sense given the frequent finding of bronchial hyperresponsiveness in viral bronchitis 1
• However, beta-2 agonists should not be routinely used in all patients - reserve for those with wheezing or particularly bothersome cough 1, 2

Antitussive Medications

• Dextromethorphan or codeine may provide modest effects on cough severity and duration in acute bronchitis (average duration 2-3 weeks) 1, 2
• These agents appear less effective for early cough from viral upper respiratory infections but may help with more prolonged cough 1

Environmental Measures

• Elimination of environmental cough triggers (dust, dander) is reasonable 1
• Vaporized air treatments may help, particularly in low-humidity environments 1

What NOT to Do

• Do not prescribe antibiotics for acute bronchitis - they reduce cough duration by only half a day while causing significant adverse effects 2
• Antibiotics are appropriate in fewer than 10% of acute bronchitis cases (those with bacterial infection) 2
• The presence of purulent sputum does NOT indicate bacterial infection and is not an indication for antibiotics 2

Critical Distinction: When Antibiotics ARE Indicated

Bacterial Pharyngitis (Strep Throat)

Antibiotics should only be considered when clinical features suggest bacterial rather than viral infection 1, 3:

• Symptoms persisting >10 days without improvement 1
• Severe symptoms: fever >39°C with purulent nasal discharge or facial pain for ≥3 consecutive days 1
• "Double sickening": worsening after initial improvement 1
• High Centor score (3-4 criteria) 3

If antibiotics are warranted for confirmed streptococcal pharyngitis, penicillin V is first-line, NOT amoxicillin-clavulanate 3

Pertussis (Whooping Cough)

• For confirmed or suspected pertussis, prescribe a macrolide antibiotic (erythromycin) 2
• Isolate patients for 5 days from start of treatment 2

Patient Communication Strategy

Setting Expectations

• Inform patients that viral sore throat typically resolves within 7 days 4
• Cough from acute bronchitis typically lasts 10-14 days after the office visit 2
• Refer to the condition as a "chest cold" rather than "bronchitis" to reduce antibiotic expectations 2

Addressing Antibiotic Expectations

• Patient satisfaction depends more on physician-patient communication than whether antibiotics are prescribed 1, 2
• Explain that antibiotics are ineffective for viral illness and do not provide direct symptom relief 1
• Discuss the harms of unnecessary antibiotic use, including adverse effects and contribution to antibiotic resistance 2

Common Pitfalls to Avoid

• Do not use broad-spectrum antibiotics like amoxicillin-clavulanate as first-line therapy - this increases resistance and side effects without additional benefit 3
• Do not assume purulent or discolored nasal discharge indicates bacterial infection - coloration relates to neutrophils, not bacteria 1
• Do not prescribe NSAIDs at anti-inflammatory doses or systemic corticosteroids for acute bronchitis 2
• Do not continue prescribing antibiotics without proper evaluation if symptoms persist beyond expected duration 4

Red Flags Requiring Further Evaluation

Refer or investigate further if 1, 2, 4:

• Tachycardia (heart rate >100 bpm), tachypnea (respiratory rate >24 breaths/min), or fever >38°C with abnormal chest examination (consider pneumonia) 2
• Symptoms persisting beyond 3 weeks (exceeds expected viral course) 4
• Unilateral tonsillar swelling with uvular deviation (peritonsillar abscess) 4
• Immunosuppression or severe systemic illness 6