What is the treatment for an otherwise healthy adult with rhinovirus infection and when to seek further evaluation?

Treatment and Management of Rhinovirus Infection in Adults

For an otherwise healthy adult with rhinovirus infection, treatment is entirely symptomatic with analgesics, nasal saline irrigation, and optionally topical intranasal corticosteroids—antibiotics should never be prescribed as they are completely ineffective for viral illness. 1

Understanding Rhinovirus Infection

• Rhinovirus is the most common cause of the common cold, accounting for up to 98% of acute viral upper respiratory infections 2
• The illness is self-limited, typically lasting 6.6 to 8.9 days, though symptoms may persist up to 15 days in 7-13% of cases without indicating bacterial infection 2
• Symptoms are caused by the host inflammatory response rather than direct viral damage to the nasal epithelium 2, 3
• Fever and myalgia typically resolve by day 5, while nasal congestion and cough may persist into weeks 2-3 without indicating bacterial infection 2

First-Line Symptomatic Treatment

Analgesics for Pain and Fever

• Acetaminophen or ibuprofen should be used for pain relief, fever control, and general discomfort 1, 2
• Pain relief is a major goal since discomfort is often the primary reason patients seek care 1
• Frequent use of analgesics is often necessary to permit patients to achieve comfort, rest, and resume normal activities 1

Nasal Saline Irrigation

• Nasal saline irrigation provides low-risk relief of congestion and facilitates clearance of nasal secretions 1, 2, 4
• Can be used multiple times daily without significant adverse effects 4
• This simple measure provides significant relief and should not be underutilized 2

Topical Intranasal Corticosteroids

• Topical intranasal corticosteroids may provide modest symptom relief, though the effect is small 1, 2, 4
• Weak evidence supports their use, but they are a reasonable option for symptomatic relief 1
• Benefits typically appear after 15 days of use with a number needed to treat of 14 4

Additional Symptomatic Options

Decongestants

• Oral decongestants (such as pseudoephedrine) may offer additional symptomatic relief 1, 2
• Use with caution in patients with hypertension, anxiety, glaucoma, benign prostatic hypertrophy, or congestive heart failure 2, 5
• Topical nasal decongestants should be limited to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 2, 5

Antihistamine/Decongestant Combinations

• First-generation antihistamine/decongestant combinations (such as brompheniramine with pseudoephedrine) are effective for reducing cough and other symptoms 2, 5
• Newer-generation nonsedating antihistamines are relatively ineffective for common cold symptoms and should not be prescribed 2, 5
• Contraindications include glaucoma, benign prostatic hypertrophy, uncontrolled hypertension, renal failure, and congestive heart failure 5

Alternative NSAID Option

• Naproxen is strongly recommended as an alternative to antihistamine-decongestant combinations 5
• Contraindications include gastrointestinal bleeding, renal failure, and congestive heart failure 5

What NOT to Prescribe

Antibiotics

• Antibiotics should NEVER be prescribed for rhinovirus infection as they are completely ineffective for viral illness and do not provide direct symptom relief 1, 2, 5, 4
• Unnecessary antibiotic prescribing adds to treatment costs, puts patients at risk of adverse events, and contributes to antimicrobial resistance 2
• Colored nasal discharge alone is NOT a reliable indicator of bacterial infection 2, 4
• Sputum color reflects neutrophil presence, not bacterial infection, and should not be used to assess the need for antibiotics 1

Systemic Corticosteroids

• Systemic corticosteroids should not be used for rhinovirus infections as they do not improve recovery and have potential for harm 4
• They are ineffective at 7-14 days and provide only minimal benefit on facial pain at days 4-7, which does not justify potential adverse events 4

Other Ineffective Agents

• Mucokinetic agents including guaifenesin are not recommended as they show no consistent favorable effect 5
• Codeine is not recommended as it has not been shown to effectively treat viral cough 5
• Dextromethorphan provides only modest effects and is less effective for early viral cough 5

When to Seek Further Evaluation

Timeframe for Bacterial Superinfection

• Bacterial sinusitis should be suspected only when symptoms persist beyond 10 days without improvement 1, 2
• "Double worsening" pattern: initial improvement followed by worsening within 10 days after onset 1
• Symptoms lasting more than 7 days do NOT necessarily indicate bacterial infection, as viral rhinovirus infections commonly last 10-15 days 2

Red Flag Symptoms Requiring Immediate Evaluation

• Severe headache, proptosis, cranial nerve palsies, or facial swelling suggest complicated rhinosinusitis 1
• High fever (≥38.3°C or 101°F) that develops or persists 1, 4
• Severe facial pain or pressure 1
• Visual changes or periorbital swelling 4
• Difficulty breathing or respiratory distress 2

Criteria for Bacterial Rhinosinusitis (ABRS)

When the following occur, consider bacterial infection and possible antibiotic therapy:

• Symptoms persist ≥10 days without evidence of improvement 1
• Symptoms worsen within 10 days after initial improvement (double worsening) 1
• Severe symptoms at presentation: moderate to severe pain AND temperature ≥38.3°C (101°F) 1

Patient Education

• Inform patients that viral symptoms typically peak within 3 days and resolve within 10-14 days 2, 5, 4
• Cough may persist 10-14 days after the office visit, even with treatment 5
• Adequate hydration and rest can favor recovery 2
• Handwashing remains the only effective method for prevention of rhinovirus transmission 6
• Patient satisfaction depends more on physician-patient communication than whether medications are prescribed 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on colored nasal discharge—this is inappropriate as color does not indicate bacterial infection 1, 2, 4
• Do not use continuous topical decongestants beyond 3-5 days to prevent rebound congestion 2, 5
• Do not prescribe newer-generation nonsedating antihistamines as they are ineffective for acute viral symptoms 2, 5
• Do not diagnose "acute bronchitis" when the common cold has not been ruled out, as this leads to inappropriate antibiotic prescribing 5