What treatment is recommended for an elderly male with a bad cold, sore throat, and nasal congestion, potentially requiring an intramuscular (IM) injection?

Treatment for Elderly Male with Cold, Sore Throat, and Nasal Congestion

An intramuscular injection is not indicated for this presentation—this is a viral upper respiratory infection (common cold) that requires only symptomatic management, not antibiotics or injections. 1

Why No Injection is Needed

• Antibiotics (including injectable penicillin) should not be prescribed for the common cold because they are not effective against viral infections and lead to significantly increased risk for adverse effects. 1
• The common cold is a benign, self-limited viral illness that typically resolves within 2 weeks without antibiotic treatment. 1
• Injectable benzathine penicillin G is indicated only for bacterial infections such as Group A streptococcal pharyngitis, not for viral upper respiratory infections. 2
• The number needed to harm from antibiotics in acute rhinosinusitis is 8, while the number needed to treat is 18—meaning antibiotics cause more harm than benefit in these viral conditions. 1, 3

Recommended Symptomatic Treatment

For symptom relief in this elderly patient, the following evidence-based options are appropriate:

Nasal Congestion Management

• Combination antihistamine-decongestant-analgesic products provide significant symptom relief in 1 out of 4 patients treated. 1
• Oral or topical decongestants may have a small positive effect on nasal congestion in adults, though should be used cautiously in elderly patients due to potential cardiovascular effects. 1
• Intranasal ipratropium bromide is effective for profuse watery rhinorrhea, which is particularly common in elderly patients due to age-related cholinergic hyperactivity, though it should be used with caution if the patient has glaucoma or prostatic hypertrophy. 1, 4
• Nasal saline irrigation can provide symptomatic relief and is safe for elderly patients. 1

Pain and Sore Throat Relief

• Ibuprofen or paracetamol (acetaminophen) are recommended for relief of sore throat symptoms and general discomfort. 1
• Paracetamol may help relieve nasal obstruction and rhinorrhea but does not improve all cold symptoms. 1
• NSAIDs produce significant benefits for headache, ear pain, and muscle/joint pain, though do not significantly reduce total symptom scores. 1

Special Considerations for Elderly Patients

• Elderly patients are more susceptible to adverse effects from rhinitis medications and may have age-related physiologic changes including cholinergic hyperactivity, mucosal atrophy, and reduced nasal blood flow. 1, 4
• Avoid first-generation antihistamines and decongestants in elderly patients due to increased risk of cognitive dysfunction, urinary retention, and cardiovascular effects. 4
• Second-generation antihistamines are generally well-tolerated by elderly patients if allergic rhinitis is a component. 4
• Consider the patient's other medications (polypharmacy) and comorbidities when selecting symptomatic treatments. 4

When to Reconsider the Diagnosis

Antibiotics would only be indicated if this is actually acute bacterial rhinosinusitis (ABRS), not a common cold:

• ABRS should be diagnosed only when symptoms persist for more than 10 days without improvement, OR there is onset of severe symptoms with high fever (>39°C) and purulent nasal discharge or facial pain lasting at least 3 consecutive days, OR worsening symptoms after initial improvement ("double sickening"). 1
• If ABRS is confirmed, oral amoxicillin-clavulanate would be the preferred antibiotic—not an intramuscular injection. 1

Key Clinical Pitfall

The most common error is prescribing antibiotics (including injectable penicillin) for viral upper respiratory infections due to patient expectations or pressure for "a shot." This practice increases antibiotic resistance, causes unnecessary adverse effects, and provides no clinical benefit. 1