What is the appropriate treatment for a patient presenting with a cough producing white phlegm, rhinorrhea, and a mild sore throat, with no severe symptoms, high fever, or difficulty breathing, and without evidence of a bacterial infection?

Treatment for Mild Upper Respiratory Infection

Do not prescribe antibiotics for this presentation—this is a viral upper respiratory infection that requires only symptomatic management. 1

Clinical Reasoning

Your patient's presentation of cough with white phlegm, rhinorrhea, and mild sore throat without fever, severe symptoms, or signs of bacterial infection is classic for a viral URI (common cold). 1 The white/clear phlegm is particularly important—contrary to popular belief, colored nasal discharge alone does not indicate bacterial infection, as mucopurulent secretions commonly occur after a few days of viral infection due to neutrophil influx. 1

When Antibiotics Are NOT Indicated

• Antibiotics provide no benefit for viral URIs and cause more harm than good—the number needed to harm from antibiotic adverse effects is 8, while the number needed to treat for any benefit is 18. 1
• Symptoms of cough and rhinorrhea commonly persist for 10-14 days in uncomplicated viral infections, with some cases lasting up to 2-3 weeks. 1
• Routine antibiotic use for acute bronchitis and common cold is not justified and should not be offered. 1

When to Consider Antibiotics (None Apply Here)

Reserve antibiotics ONLY for: 1

• Persistent symptoms >10 days without improvement
• Severe symptoms: High fever >39°C (102.2°F) AND purulent nasal discharge or facial pain for ≥3 consecutive days
• "Double sickening": Worsening after initial improvement following 5 days of typical viral illness

Recommended Treatment Algorithm

First-Line Symptomatic Management

• Combination antihistamine-decongestant products (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine): 1 in 4 patients achieves significant symptom relief. 1
• Analgesics (acetaminophen or ibuprofen) for sore throat discomfort. 1
• Simple supportive measures: Honey and lemon, adequate hydration, voice rest. 2, 3

For Bothersome Cough

• Inhaled ipratropium bromide 2-3 puffs four times daily has the strongest evidence for attenuating post-infectious cough. 4, 2, 3
• Dextromethorphan 60 mg provides maximum cough reflex suppression with fewer side effects than codeine. 2
• Intranasal saline irrigation may alleviate symptoms. 1

Additional Options

• Intranasal corticosteroids (fluticasone or mometasone) can decrease airway inflammation if symptoms are particularly bothersome. 4
• Zinc supplements may reduce symptom duration if started early in healthy persons. 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics for viral URI or acute bronchitis—they contribute to antimicrobial resistance and cause adverse effects including allergic reactions and C. difficile infection. 1, 3
• Do not use nasal decongestant sprays >3-5 days due to rebound congestion risk. 4, 3
• Do not assume bacterial infection based on colored phlegm alone—this is a normal progression of viral infection. 1

When to Reassess

Advise the patient to follow up if: 1

• Symptoms persist beyond 10 days without improvement
• Symptoms worsen after initial improvement (double sickening)
• High fever (>39°C) develops with severe facial pain
• Paroxysmal coughing with post-tussive vomiting develops (consider pertussis, which requires macrolide antibiotics and isolation). 4, 3

Symptoms can last up to 2 weeks and should be expected to gradually improve without antibiotics. 1