What is the initial management for an adult patient presenting with cough, chest congestion, sore throat, and nasal congestion, suggestive of an upper respiratory tract infection?

Initial Management of Acute Upper Respiratory Tract Infection

For an adult presenting with cough, chest congestion, sore throat, and nasal congestion consistent with acute viral upper respiratory infection, do NOT prescribe antibiotics, as they provide no benefit for viral illness and drive antibiotic resistance. 1

Immediate Assessment

Rule out pneumonia first by checking for these specific findings 2, 1:

• Fever >38°C persisting >4 days
• Tachypnea or significant dyspnea
• New focal chest examination findings (crackles, bronchial breathing, dullness to percussion)
• Abnormal vital signs

Order chest radiography only if any of the above pneumonia indicators are present 2, 1. In the absence of these findings, pneumonia likelihood is sufficiently low that imaging is unnecessary 1.

Evidence-Based Symptomatic Treatment

For Sore Throat and General Discomfort

• Acetaminophen or ibuprofen for pain relief and any fever 1
• Throat lozenges for additional sore throat relief 1

For Nasal Congestion

• Pseudoephedrine (oral decongestant) as first-line for nasal congestion 1
• Intranasal corticosteroids (fluticasone propionate 100-200 mcg daily) are most effective for persistent nasal congestion, particularly if symptoms suggest rhinitis component 3, 4
• Avoid antihistamines as monotherapy—they are ineffective for URI symptoms unless combined with decongestants 1

For Cough Management

• Provide reassurance that cough typically peaks at days 3-6 and resolves within 3 weeks, even without treatment 1
• Inhaled ipratropium bromide is the only recommended cough suppressant if cough persists beyond 3-5 days and is bothersome 1
• Do NOT prescribe benzonatate or other cough suppressants—they have limited efficacy in acute viral infections 1

General Measures

• Adequate hydration and rest 1
• Nasal saline irrigation for congestion relief 5

Expected Clinical Course and Follow-Up

Symptoms should peak at days 3-6 and begin improving thereafter 1. Most uncomplicated viral URIs resolve within 5-7 days, though post-infectious cough may persist up to 3 weeks 1.

Instruct the patient to return if 1:

• Symptoms persist >10 days without improvement
• Symptoms worsen after initial improvement (suggests secondary bacterial infection)
• New focal chest findings or significant dyspnea develop (reconsider pneumonia)
• Fever persists >4 days

Critical Pitfalls to Avoid

Never prescribe antibiotics for uncomplicated URI 1. Multiple randomized controlled trials demonstrate antibiotics do not reduce symptom duration or severity, even in patients with purulent sputum or prolonged cough up to 3 weeks 1. Inappropriate antibiotic use is the primary driver of community-acquired respiratory pathogen resistance 1.

Distinguish viral rhinosinusitis from bacterial sinusitis 1. Routine congestive rhinosinusitis accompanying viral URI does not require antibiotics 1.

If cough persists beyond 8 weeks, reclassify as chronic cough and initiate systematic evaluation starting with upper airway cough syndrome treatment 6. At this threshold, the post-infectious explanation no longer applies 6.

Consider pertussis if the patient has paroxysmal cough, post-tussive vomiting, or inspiratory whooping sound—obtain nasopharyngeal culture and prescribe macrolide antibiotics if confirmed 6.