What is the best treatment for an otherwise healthy adult male with viral upper respiratory infection (URI) symptoms of cough, sore throat, and congestion?

Treatment of Viral Upper Respiratory Infection

For an otherwise healthy adult male with viral URI symptoms of cough, sore throat, and congestion, antibiotics should NOT be prescribed, and treatment should focus on symptomatic relief with over-the-counter analgesics (acetaminophen or ibuprofen), oral decongestants, first-generation antihistamines, nasal saline irrigation, and optionally intranasal corticosteroids. 1, 2

Key Diagnostic Principle

• Viral URI is a self-limited illness that typically peaks within 3 days and resolves within 10-14 days without antibiotics 1
• Purulent or discolored nasal discharge does NOT indicate bacterial infection—it simply reflects inflammation and neutrophil presence, not bacteria 1
• Bacterial superinfection should only be suspected if symptoms persist beyond 10 days, worsen after 5-7 days ("double sickening"), or present with severe features 1, 2

Evidence-Based Symptomatic Treatment

First-Line Therapies

• Analgesics/Antipyretics: Acetaminophen, ibuprofen, or naproxen for pain, sore throat, and fever provide effective symptom relief 1
• Nasal Saline Irrigation: Safe with low risk of adverse effects and provides minor but consistent improvement in nasal symptoms 1, 3
• Oral Decongestants (pseudoephedrine/phenylephrine): Provide symptomatic relief of congestion unless contraindicated by hypertension or anxiety 1
• First-Generation Antihistamines (brompheniramine, diphenhydramine): Combined with decongestants, these lead to more rapid improvement in cough, throat clearing, and post-nasal drip compared to placebo 1

Important Caveat on Antihistamines

• Newer "non-sedating" antihistamines are relatively ineffective for common cold symptoms 1
• Only first-generation antihistamines combined with decongestants have demonstrated efficacy 1

Optional Therapies

• Intranasal Corticosteroids: May provide modest benefit for nasal congestion and facial pressure (73% improvement vs 66% with placebo at 14-21 days), though not FDA-approved for this indication 1
• Topical Decongestants: Can be used short-term (≤3-5 days maximum) to avoid rebound congestion and rhinitis medicamentosa 1
• Cough Suppressants (dextromethorphan) and Expectorants (guaifenesin): Evidence of clinical efficacy is lacking, but may be used based on patient preference 1, 4, 5

What NOT to Do

• Do NOT prescribe antibiotics: They are ineffective for viral illness, provide no symptom relief, and increase adverse effects with a number needed to harm of 8 1, 2
• Avoid β-agonists (albuterol) unless the patient has underlying asthma or COPD—they do not benefit otherwise healthy adults 1
• Avoid prolonged topical decongestant use beyond 3-5 days 1

Patient Education and Safety Netting

• Counsel patients that viral URI is self-limited and typically resolves within 10-14 days 1, 2
• Emphasize hand hygiene and respiratory etiquette to prevent transmission 2
• Provide return precautions: fever >100.4°F, respiratory distress, symptoms persisting beyond 10 days, or worsening after initial improvement 2

Clinical Decision Algorithm

1. Confirm viral etiology: Symptoms <10 days, no severe features (high fever >39°C for ≥3 days, severe unilateral facial pain), no "double sickening" pattern 1, 2
2. Rule out pneumonia: Check for tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever (>38°C), and abnormal chest exam findings (rales, egophony, fremitus)—if all absent, pneumonia is unlikely 1
3. Initiate symptomatic treatment: Start with analgesics and nasal saline; add oral decongestant and first-generation antihistamine for moderate-to-severe symptoms 1
4. Consider optional therapies: Intranasal corticosteroids for persistent nasal congestion, short-term topical decongestants if needed 1
5. Avoid antibiotics entirely unless bacterial superinfection is clearly suspected based on duration or severity criteria 1, 2

Common Pitfalls to Avoid

• Mistaking purulent discharge for bacterial infection: Discolored mucus is normal in viral URI and does not warrant antibiotics 1
• Prescribing antibiotics for patient satisfaction: This increases antimicrobial resistance and causes harm without benefit 1, 2
• Using newer antihistamines: Only first-generation antihistamines combined with decongestants have proven efficacy 1
• Prolonged topical decongestant use: Leads to rebound congestion 1