What is the first line treatment for adults and children presenting with fever, cough, and cold symptoms?

First-Line Treatment for Fever, Cough, and Cold Symptoms

For adults and children presenting with fever, cough, and cold symptoms, symptomatic treatment with first-generation antihistamine/decongestant combinations (such as brompheniramine or dexbrompheniramine with pseudoephedrine) or naproxen (500 mg twice daily in adults) is the recommended first-line approach, while antibiotics should be avoided as they provide no benefit and cause harm. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, you must rule out life-threatening conditions and distinguish the common cold from other causes of acute cough:

• Exclude pneumonia by confirming absence of focal chest signs, tachypnea (>30 breaths/min in adults), hypoxemia (SpO2 <90%), or infiltrates on chest radiograph if obtained 1
• Rule out acute bronchitis diagnosis unless the common cold has been definitively excluded, as acute bronchitis is frequently overdiagnosed and leads to inappropriate antibiotic prescribing in 65-80% of cases 1
• Differentiate from asthma exacerbation or COPD exacerbation, as 30-65% of patients with these conditions are misdiagnosed as having acute bronchitis 1
• Identify the common cold by the presence of nasal stuffiness and discharge, sneezing, sore throat, and cough, with or without fever, lasting less than 3 weeks 1

Recommended First-Line Treatments

For Adults

Primary options:

• First-generation antihistamine/decongestant combinations provide substantial benefit for nasal congestion, postnasal drainage, sneezing, and cough 1, 2
• Naproxen 500 mg twice daily reduces cough associated with the common cold with specific evidence supporting its use 1, 2
• NSAIDs (acetaminophen or ibuprofen) provide relief for headache, malaise, myalgia, and fever 3

Adjunctive measures:

• Zinc acetate or gluconate lozenges at doses ≥75 mg/day taken within 24 hours of symptom onset significantly reduce cold duration 3
• Short-term nasal decongestants (3-5 days maximum) reduce nasal blockage but must be discontinued to avoid rebound congestion 2, 3

For Children

Primary approach:

• Avoid over-the-counter cough and cold medications in children younger than 4 years due to potential harm and no demonstrated benefits 4
• Acetaminophen or ibuprofen for fever and pain relief 4

Effective symptomatic treatments for children:

• Buckwheat honey (for children >1 year) improves cough symptoms 4
• Vapor rub provides symptom relief 4
• Zinc sulfate reduces symptom duration 4
• Nasal saline irrigation reduces symptom severity 4

Medications to Explicitly Avoid

Never prescribe antibiotics for uncomplicated common cold or acute bronchitis, as they:

• Provide no benefit for symptom reduction or illness duration 1, 5
• Significantly increase adverse effects in adults (odds ratio 3.6) 5
• Contribute to antibiotic resistance 1, 5
• Are only indicated if bacterial pneumonia or pertussis is confirmed 1

Avoid these ineffective treatments:

• Newer-generation nonsedating antihistamines (loratadine, cetirizine, fexofenadine) are completely ineffective for common cold symptoms 2, 3, 4
• Intranasal corticosteroids have no benefit for the common cold 2, 3
• Codeine has not been shown to effectively treat cough from the common cold 6
• Dextromethorphan may benefit adults but effectiveness is not demonstrated in children and adolescents 6
• Inhaled bronchodilators (albuterol) should be avoided unless underlying asthma is present 2

Expected Clinical Course and Red Flags

Normal progression:

• Cough should be worst during the first few days and gradually improve over 1-2 weeks 2
• Symptoms lasting beyond 3 weeks require reevaluation for alternative diagnoses 1, 2

Indications for reassessment or escalation:

• Fever persisting beyond 48 hours after starting symptomatic treatment 1
• Cough worsening after initial improvement 2
• Development of focal chest signs, dyspnea, or hypoxemia 1
• Symptoms suggesting bacterial sinusitis (persistent purulent nasal discharge >10 days, facial pain, maxillary tooth pain) 1
• Suspected pertussis (paroxysmal cough, post-tussive emesis, inspiratory whoop) requires macrolide antibiotic therapy 1

Special Considerations for Comorbidities

Patients with diabetes:

• Continue current insulin regimen without modification, as recommended cold medications do not interact with insulin 2
• Monitor blood glucose more frequently during acute illness 2
• Pseudoephedrine has minimal effect on blood glucose in most patients but monitor for hyperglycemia 2

Patients with hypertension:

• Use decongestants cautiously as they may elevate blood pressure 2

Critical Pitfalls to Avoid

• Do not prescribe antibiotics simply because patients have colored (yellow or green) sputum, as this does not indicate bacterial infection 1
• Do not use nasal decongestants for more than 3-5 days to prevent rebound congestion 2
• Do not use combination cold medications unless they contain first-generation antihistamine/decongestant ingredients, as most over-the-counter combinations lack efficacy evidence 2
• Do not delay appropriate treatment by waiting for unnecessary diagnostic tests in patients with clear viral upper respiratory infection 2