Treatment of Acute Upper Respiratory Infection with Fever, Productive Cough, Cold Symptoms, and Sore Throat
Do NOT Prescribe Antibiotics
Antibiotics should not be prescribed for this presentation—this is a viral illness requiring only symptomatic management, and antibiotic use provides no benefit while causing harm through adverse effects and antimicrobial resistance. 1, 2
The vast majority of these presentations are viral in origin, and even when bacterial pathogens are present, antibiotics show minimal benefit (number needed to treat = 18 for rapid cure, but number needed to harm = 8 for adverse effects). 1
Recommended Prescription Medications
First-Line Analgesic/Antipyretic Therapy
Prescribe ibuprofen 400-800 mg every 6-8 hours as the preferred first-line agent for fever, sore throat pain, headache, and body aches—it demonstrates superior efficacy compared to acetaminophen, particularly for pain relief within 2 hours. 3, 2
- Alternative: Acetaminophen/paracetamol 500-1000 mg every 6 hours if ibuprofen is contraindicated 3, 2
- Both medications are safe for short-term use with low risk of adverse effects 3
- Ibuprofen additionally improves sneezing and provides broader symptom relief 2
Combination Therapy for Cold Symptoms
Prescribe a combination antihistamine-decongestant-analgesic product as this provides the most effective symptomatic relief, with 1 in 4 patients experiencing significant improvement (odds ratio of treatment failure 0.47; number needed to treat = 5.6). 2
- Effective combination: First-generation antihistamine (brompheniramine) + sustained-release pseudoephedrine + analgesic 2
- This combination is superior to single-agent therapy for congestion and rhinorrhea 2
Additional Symptomatic Prescriptions
For productive cough: Prescribe dextromethorphan 60 mg (maximum effective dose), though standard over-the-counter doses are likely subtherapeutic. 2
For rhinorrhea: Prescribe ipratropium bromide nasal spray 0.03% (2 sprays per nostril 3-4 times daily)—this effectively reduces nasal discharge but does not improve congestion. 2
For nasal congestion: Prescribe topical nasal decongestant (oxymetazoline or phenylephrine) but limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa). 2
Over-the-Counter Recommendations (Non-Prescription)
- Zinc lozenges (≥75 mg/day zinc acetate or gluconate) ONLY if symptoms started within the last 24 hours—no benefit if symptoms are already established beyond 24 hours 2, 4
- Honey and lemon as a simple home remedy with patient-reported benefit 2
- Nasal saline irrigation for modest symptom relief 2
- Oral pseudoephedrine (if not already in combination product) provides modest benefit for congestion 2
Critical Red Flags Requiring Re-Evaluation
Instruct the patient to return immediately or seek urgent care if any of the following develop:
- Fever >38.5°C (101.3°F) persisting beyond 3 days or appearing after initial improvement 1, 5, 2
- "Double sickening" pattern (initial improvement followed by worsening symptoms) 1, 5, 2
- Shortness of breath at rest or with minimal activity 1
- Coughing up bloody sputum 1
- Severe unilateral facial pain suggesting bacterial sinusitis 5, 2
- Drowsiness, disorientation, or confusion 1
- Difficulty swallowing, drooling, or neck swelling (concern for peritonsillar abscess or epiglottitis) 1
When to Consider Antibiotics (Specific Criteria Only)
For Streptococcal Pharyngitis
Test for group A Streptococcus if the patient has persistent fever, anterior cervical adenitis, and tonsillopharyngeal exudates (3-4 Centor criteria). 1, 3
- Use rapid antigen detection test and/or throat culture 1
- Only prescribe antibiotics if test is positive: Penicillin V for 10 days or amoxicillin 1, 6
- Do NOT prescribe antibiotics for negative streptococcal testing 1, 3
For Bacterial Rhinosinusitis
Only suspect bacterial infection if at least 3 of the following 5 criteria are present: 5, 2
- Discolored (purulent) nasal discharge
- Severe local facial pain
- Fever >38°C (100.4°F)
- "Double sickening" pattern
- Elevated inflammatory markers
Do NOT diagnose bacterial sinusitis in the first 10 days of symptoms—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics. 2
- If bacterial sinusitis is confirmed: Amoxicillin is the antibiotic of choice 6
- Alternative: Cefaclor or cephalexin for recurrent/chronic cases 6
Expected Clinical Course and Patient Education
- Typical duration: 7-10 days for most symptoms 2, 4
- Up to 25% of patients will have cough and nasal discharge persisting for 14 days—this is normal and does NOT indicate bacterial infection 5, 2
- Symptoms persisting >10 days without improvement classify as post-viral rhinosinusitis and may benefit from intranasal corticosteroids 5, 2
- Only 0.5-2% of viral upper respiratory infections develop bacterial complications 5, 2
Pediatric Considerations (If Patient is a Child)
- Acetaminophen/paracetamol is first-line for fever and pain in children 3, 2
- Aspirin is absolutely contraindicated in children under 16 years due to Reye syndrome risk 1
- Over-the-counter cough and cold medications should NOT be used in children younger than 4 years due to potential harm without benefit 4
- Children under 1 year or those at high risk should be seen and assessed by a physician 1
- Effective pediatric options: Vapor rub, zinc sulfate, buckwheat honey (>1 year old), and Pelargonium sidoides extract 4
What Does NOT Work (Avoid These)
- Intranasal corticosteroids for acute cold symptoms (only helpful for post-viral rhinosinusitis >10 days) 2
- Non-sedating antihistamines (newer generation) are ineffective 2
- Echinacea preparations show inconsistent results 4
- Vitamin C for treatment (only modestly effective as prophylaxis) 4
- Opiate antitussives due to significant adverse effects without clear superiority 2
- Zinc gluconate for sore throat treatment due to conflicting efficacy and increased adverse effects 3