What is the treatment approach for viral upper respiratory infections (URIs)?

Treatment of Viral Upper Respiratory Infections

Viral URIs should be managed with symptomatic treatment only—antibiotics must never be prescribed as they provide no benefit, cause harm through adverse effects and antibiotic resistance, and the number needed to harm (8) is far lower than the number needed to treat (18). 1, 2, 3

Core Symptomatic Treatment Approach

First-Line Therapies

• Analgesics/antipyretics (acetaminophen or ibuprofen) for pain relief and fever control—this addresses the primary reason patients seek care 1, 2, 3
• Nasal saline irrigation provides cleansing effects, relieves congestion, and facilitates clearance of secretions with minimal adverse effects 1, 2, 3
• Adequate hydration to thin secretions and support recovery 1
• Rest and maintaining comfortable humidity levels in the home 1

Additional Symptomatic Options

• Oral decongestants (e.g., pseudoephedrine) may provide symptomatic relief of congestion, but avoid in patients with hypertension or anxiety 2, 3, 4
• Topical nasal decongestants can be used but strictly limit to 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa) 2, 3
• First-generation antihistamine/decongestant combinations (sustained-release pseudoephedrine with brompheniramine) may reduce symptoms through a drying effect, though evidence is limited 3
• Topical intranasal corticosteroids may provide modest symptom relief 2, 3

Expected Clinical Course

Viral URIs follow a predictable pattern that helps distinguish them from bacterial complications 1, 2:

• Symptoms typically peak around days 3-6 and resolve within 10-14 days 1, 2
• Fever, when present, occurs early and resolves within 24-48 hours 1
• Nasal discharge changes from clear/watery to thick/purulent for several days, then returns to clear before resolving 1
• The color of nasal discharge does NOT indicate bacterial infection—discolored discharge simply reflects neutrophil presence and inflammation 2, 3

Critical: When to Suspect Bacterial Infection

Suspect acute bacterial sinusitis requiring antibiotics only when 5, 1, 2:

• Persistent symptoms ≥10 days without improvement, OR
• "Double worsening": initial improvement followed by worsening within 10 days, OR
• Severe onset: high fever (>39°C) with purulent nasal discharge and facial pain for at least 3-4 consecutive days 5, 1

Do NOT obtain imaging studies to distinguish viral URI from bacterial sinusitis 1

What NOT to Do

Never Prescribe Antibiotics for Viral URIs

The evidence against antibiotic use is overwhelming 5, 1, 2, 3:

• Antibiotics are completely ineffective for viral illness 2, 3
• Over 80% of ambulatory sinusitis visits result in unnecessary antibiotic prescriptions 2
• Number needed to harm (8) is much lower than number needed to treat (18) 2
• Excessive antibiotic use drives antimicrobial resistance at individual and community levels 5, 2
• Increases risk of C. difficile colitis, especially in children 5

Other Treatments to Avoid

• Systemic corticosteroids have not shown effectiveness for viral rhinitis 3
• Newer non-sedating antihistamines are relatively ineffective for common cold symptoms 3
• Guaifenesin and dextromethorphan lack evidence of clinical efficacy 3

Special Populations

Pediatric Considerations

• Use age-appropriate dosing for all medications 1, 2
• Avoid decongestants and antihistamines in children under 3 years due to potential adverse effects 3
• Children in daycare may have more protracted symptoms (up to 13% lasting >15 days) 5
• Observation or "delayed prescribing" strategies reduce antibiotic use without worse outcomes when supported by close follow-up 5

High-Risk Patients

• Patients with chronic respiratory conditions (e.g., asthma) require closer monitoring 3
• Consider immediate evaluation for patients with history of recurrent bacterial sinusitis 5

When to Seek Further Medical Attention

Advise patients to return if 1:

• Persistent high fever for more than 3 days
• Worsening symptoms after initial improvement
• Symptoms persisting beyond 10 days without improvement
• Signs of respiratory distress
• Severe symptoms with concurrent high fever and purulent discharge for 3-4 days

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on colored nasal discharge—this is the most common error, as color does not indicate bacterial infection 2, 3
• Do not use symptom duration <10 days as justification for antibiotics—bacterial sinusitis is uncommon before 10 days 5
• Do not underutilize simple measures like saline irrigation and adequate hydration, which provide significant relief 3
• Do not allow topical decongestant use beyond 3-5 days, as rebound congestion will worsen the patient's condition 2, 3