What is the appropriate treatment for a 13-year-old girl presenting with fever, sore throat, cough, and congestion?

Management of a 13-Year-Old Girl with Fever, Sore Throat, Cough, and Congestion

This presentation is most likely a viral upper respiratory tract infection that should be managed with supportive care alone—antibiotics are not indicated and cause more harm than benefit. 1, 2

Initial Assessment: Rule Out Red Flags

Before proceeding with outpatient management, immediately assess for signs requiring hospital referral 1, 3:

• Respiratory distress (markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs) 1
• Cyanosis or oxygen saturation <92% 1, 3
• Severe dehydration 1
• Altered conscious level or drowsiness 1
• Signs of septicemia (extreme pallor, hypotension) 1

If any red flags are present, refer immediately for hospital admission with IV antibiotics. 1, 3

Determine if This is Viral or Bacterial

Most Likely Diagnosis: Viral URI

The combination of fever, sore throat, cough, AND congestion strongly suggests a viral upper respiratory tract infection, which accounts for the vast majority of these presentations in adolescents. 1, 4, 2 Upper respiratory tract infections occur above the vocal cords with normal pulmonary auscultation and are predominantly viral. 4

When to Consider Bacterial Infection

For Group A Streptococcal Pharyngitis:

• Do NOT diagnose based on symptoms alone 1, 2
• The presence of cough and congestion actually argues AGAINST strep throat 5, 6
• Testing (rapid antigen or throat culture) is required ONLY if clinical suspicion is high 1, 2
• Antibiotics should never be prescribed without positive testing 1, 2

For Acute Bacterial Sinusitis:

• Requires one of three specific patterns 4:
  • Persistent symptoms ≥10 days without improvement 4
  • Worsening symptoms (double sickening pattern after initial improvement) 4
  • Severe symptoms (fever ≥39°C with purulent nasal discharge for ≥3 consecutive days) 4
• Since this patient's duration is not specified as >10 days, bacterial sinusitis is unlikely 4

For Pneumonia:

• Would require abnormal lung auscultation or signs of respiratory distress 1
• Not suggested by this presentation 1

Recommended Treatment: Supportive Care

Primary management should focus on symptom relief, not temperature normalization: 7

Antipyretics and Analgesics

• Ibuprofen is preferred over acetaminophen for fever and pain in adolescents due to longer duration of action (every 6-8 hours vs. every 4 hours) and superior antipyretic efficacy 7, 8
• Acetaminophen is an acceptable alternative 7, 8
• Never use aspirin in patients under 16 years of age 1

Additional Supportive Measures

• Rest and adequate fluid intake 1
• Saline nasal irrigation for congestion 4
• Intranasal corticosteroids for symptom relief 4
• Topical decongestants (short course) or throat lozenges as needed 1

When Antibiotics Are NOT Indicated

Antibiotics should NOT be prescribed for: 1, 2

• Common cold 1, 2
• Nonspecific upper respiratory infection 1, 2
• Acute bronchitis 1, 2
• Viral pharyngitis 1, 2

The American Academy of Pediatrics explicitly states that antibiotics cause more harm than benefit in these viral conditions and contribute to antibiotic resistance. 1, 2

Mandatory Reassessment Strategy

Instruct the patient (and parents) to return or re-consult if: 1, 3

• Fever persists for 4-5 days without improvement or worsens 1
• Symptoms persist beyond 10 days without improvement (suggests bacterial sinusitis) 4
• Worsening after initial improvement (double sickening pattern) 4
• Development of severe symptoms: shortness of breath, painful breathing, bloody sputum, drowsiness, or confusion 1
• Severe earache develops 1
• Vomiting >24 hours 1

Reassessment at 48-72 hours is critical to detect complications such as pneumonia or bacterial superinfection that would require antibiotic therapy. 1, 3

Critical Pitfalls to Avoid

• Do not prescribe antibiotics empirically for viral URI symptoms—this exposes the patient to unnecessary harm (diarrhea, rash, C. difficile colitis) and drives antibiotic resistance 1, 2
• Do not use first-generation cephalosporins (like cephalexin) for respiratory infections, as they have inadequate activity against S. pneumoniae 4, 3
• Do not prescribe azithromycin as first-line for respiratory infections due to S. pneumoniae resistance 1
• Do not delay reassessment, as complications can develop rapidly 3