What are the recommended treatments and dosages for viral upper respiratory infections (URI)?

Treatment and Dosing for Viral Upper Respiratory Infections

Viral URIs should be managed with symptomatic treatment only—antibiotics are not indicated and provide no benefit for viral illness. 1

Core Management Principles

Symptomatic relief is the primary goal of treatment, as viral URIs are self-limited infections that typically resolve within 7-14 days. 1 The innate immune response mechanisms are similar across all respiratory viruses, making symptom-directed therapy appropriate regardless of the specific viral pathogen 2.

First-Line Symptomatic Treatments

Analgesics and Antipyretics:

• Acetaminophen or ibuprofen for pain, fever, and myalgias 1
• Ibuprofen dosing: 200 mg orally every 4-6 hours as needed (maximum 4 times in 24 hours) 1
• NSAIDs (ibuprofen, naproxen) are effective for pain and fever relief 1, 3

Nasal Decongestants:

• Oral decongestants provide symptomatic relief and should be considered unless contraindicated (hypertension, anxiety) 1
• Topical decongestants may be used but should NOT exceed 3-5 days to avoid rebound congestion and rhinitis medicamentosa 1

Nasal Saline:

• Nasal saline irrigation is safe and provides minor improvements in nasal symptoms with low risk of adverse effects 1
• Can be used in both physiologic and hypertonic concentrations 1

Additional Symptomatic Options

Antihistamines:

• First-generation (sedating) antihistamines may provide relief of excessive secretions and sneezing through anticholinergic effects 1
• More effective than second-generation antihistamines for URI symptoms due to CNS penetration and anticholinergic activity 1

Cough Suppressants:

• Dextromethorphan can be offered for short-term symptomatic relief of coughing 1
• Evidence is mixed, but may provide subjective improvement 1

Expectorants:

• Guaifenesin is commonly used but evidence of clinical efficacy is lacking 1
• Decision to use is based largely on patient and provider preference 1

Intranasal Corticosteroids:

• May provide modest benefit for facial pain and nasal congestion (66% improved with placebo vs 73% with steroid at 14-21 days) 1
• Not FDA-indicated for viral URI but adverse events are rare 1
• Choice should be based on patient preference given small magnitude of benefit 1

Critical Pitfalls to Avoid

What NOT to Do:

• Do NOT prescribe antibiotics for viral URI—they are ineffective for viral illness, do not provide symptom relief, and contribute to antibiotic resistance 1
• Do NOT use topical decongestants for more than 3-5 days due to risk of rebound congestion 1
• Do NOT use systemic corticosteroids for uncomplicated viral URI—they are not indicated for mild illness 1
• Do NOT assume purulent nasal discharge indicates bacterial infection—discolored discharge reflects neutrophil presence from inflammation, not bacteria 1

When to Consider Bacterial Infection

Suspect bacterial rhinosinusitis (requiring antibiotics) only if:

• Symptoms persist >10 days without improvement 1, 4
• Symptoms worsen after initial improvement ("double worsening") 1
• Severe symptoms at onset: fever >39°C (102.2°F), purulent discharge, and facial pain for ≥3-4 consecutive days 1, 4

For bacterial pharyngitis:

• Prescribe antibiotics ONLY if rapid strep test or culture is positive 4

Duration and Expected Course

• Symptoms typically peak within 3 days, then gradually decline 1
• Most viral URIs resolve within 7-10 days, though some symptoms may persist up to 14 days 1, 5
• Cough and nasal congestion may persist into the second or third week and still represent uncomplicated viral infection 1
• Approximately 7-13% of children may have symptoms lasting >15 days without bacterial infection 1

Special Populations

Children <6 years:

• The FDA advises against use of over-the-counter cough and cold medications 4

Athletes:

• Most viral URIs result in little time lost from athletic participation with appropriate symptomatic management 5