What is the best course of treatment for a 56-year-old male with intermittent cough, nasal congestion, and runny nose with yellow mucus, without fever, chills, wheezing, nausea, or vomiting?

Treatment of Viral Upper Respiratory Infection with Cough and Nasal Congestion

This is a viral upper respiratory infection (common cold/viral rhinosinusitis) that does not require antibiotics and should be managed with symptomatic treatment only. 1, 2

Why Antibiotics Are Not Indicated

• The absence of fever, chills, and systemic symptoms strongly argues against bacterial infection 1, 2
• Yellow nasal mucus alone does not indicate bacterial infection—purulence is caused by inflammatory cells and sloughed epithelial cells, not bacteria 1
• Only 0.5-2% of viral URIs develop bacterial complications 2
• Antibiotics are ineffective for viral infections and contribute to resistance and adverse effects 1, 2
• Bacterial sinusitis should only be considered if symptoms persist beyond 10 days without improvement, worsen after initial improvement, or if severe symptoms (high fever ≥39°C, severe facial pain, purulent discharge) occur for ≥3 consecutive days 1, 2

First-Line Symptomatic Treatment

Analgesics/Antipyretics:

• Acetaminophen 650-1000 mg or ibuprofen for pain relief 1, 2

Nasal Saline Irrigation:

• Helps relieve symptoms and remove thick mucus 1, 2

Oral Decongestants:

• Pseudoephedrine 30-60 mg every 4-6 hours for nasal congestion 2, 3
• Monitor for side effects: insomnia, jitteriness, tachycardia, worsening hypertension 1, 4

Topical Nasal Decongestants (Short-term only):

• Oxymetazoline spray may provide rapid relief 1
• Critical warning: Use for maximum 3-5 days only to avoid rhinitis medicamentosa (rebound congestion) 1, 2, 4

Treatment for Productive Cough

Guaifenesin (Expectorant):

• 200-400 mg every 4 hours to help loosen phlegm and thin bronchial secretions 2, 5
• Evidence for clinical efficacy is limited, but it is FDA-approved for this indication 2, 5

Cough Suppressants (if needed for dry/irritating cough):

• Dextromethorphan 15-30 mg every 6-8 hours 1
• Consider higher doses (up to 60 mg) for maximum effect, though most over-the-counter preparations contain subtherapeutic amounts 1

Optional Adjunctive Therapies

Intranasal Corticosteroids:

• May provide modest benefit after 15 days of use (about 1 in 14 patients benefit) 1
• Consider fluticasone, mometasone, or budesonide nasal spray 1, 6
• Side effects include headache, nasal itching, and nosebleeds 1

First-Generation Antihistamines (for nighttime use):

• Diphenhydramine 25-50 mg at bedtime may help with rhinorrhea and allow sleep 1
• Avoid in patients needing to remain alert due to sedation 1

What NOT to Do

• Do not prescribe antibiotics—this is the most common error, occurring in >80% of sinusitis visits 2
• Do not use topical decongestants beyond 3-5 days 1, 2, 4
• Do not routinely use oral antihistamines or systemic corticosteroids for viral URI—they do not relieve symptoms and have unnecessary side effects 1
• Second-generation antihistamines (cetirizine, loratadine) are ineffective for non-allergic viral rhinitis 1, 4

Expected Clinical Course and Follow-up

• Viral URI symptoms typically peak within 3 days and resolve within 10-14 days 2
• Cough may persist for up to 3 weeks after other symptoms resolve 1
• Reassess if symptoms persist beyond 10 days without improvement, worsen after initial improvement, or if high fever/severe facial pain develops 1, 2

Patient Education Points

• This is a viral infection that will resolve on its own 1
• Antibiotics will not help and may cause side effects 1
• Simple home remedies like honey and lemon may provide as much relief as over-the-counter medications 1
• Practice good hand hygiene and respiratory etiquette to avoid spreading infection 1
• Return if symptoms worsen, persist beyond 10-14 days, or if new concerning symptoms develop 1, 2