What is the best treatment approach for a patient presenting with an Upper Respiratory Tract Infection (URTI) with a main symptom of dry cough?

Treatment of URTI with Dry Cough as Main Symptom

For a patient with URTI presenting with dry cough as the main symptom, provide symptomatic relief with analgesics and consider dextromethorphan or codeine for bothersome cough, while avoiding antibiotics entirely as this is a self-limited viral illness. 1

Understanding the Clinical Context

URTI-associated dry cough is a benign, self-limited condition that typically peaks within 3 days and resolves within 10-14 days without intervention. 1 The cough duration rarely exceeds 2 weeks in uncomplicated cases. 2 This is purely viral in etiology and does not benefit from antibiotics. 1

Primary Symptomatic Management

First-Line Therapy: Analgesics

• Prescribe acetaminophen, ibuprofen, or naproxen for associated pain, sore throat, and fever—these provide effective symptom relief and address the systemic discomfort that often accompanies URTI. 1, 3

Cough-Specific Treatment

• For dry, bothersome cough, prescribe dextromethorphan or codeine as cough suppressants. 2, 4 These are the only antitussive agents with guideline support for acute URTI-associated dry cough. 2
• Dextromethorphan is FDA-approved as a cough suppressant and available in extended-release formulations providing 12-hour relief. 4
• The evidence for antitussives is mixed—some studies show benefit while others do not—but guidelines support their use when cough is sufficiently bothersome to interfere with daily activities or sleep. 2, 5

Adjunctive Symptomatic Measures

• Nasal saline irrigation is safe with low risk of adverse effects and provides minor but consistent improvement in nasal symptoms. 1
• Oral decongestants (pseudoephedrine/phenylephrine) can relieve congestion unless contraindicated by hypertension or anxiety. 1
• First-generation antihistamines (brompheniramine, diphenhydramine) combined with decongestants may provide more rapid improvement in cough, throat clearing, and post-nasal drip compared to placebo. 1

What NOT to Do

Avoid Antibiotics Entirely

• Do not prescribe antibiotics for viral URTI with dry cough. 1 Antibiotics are ineffective against viral infections, increase adverse effects, and contribute to antimicrobial resistance. 1
• Purulent or discolored nasal discharge does NOT indicate bacterial infection—it simply reflects inflammation and neutrophil presence, not bacteria. 1
• Bacterial superinfection should only be suspected if symptoms persist beyond 10 days, worsen after 5-7 days, or present with severe features (high fever >4 days, dyspnea, new focal chest signs). 2, 1

Avoid Ineffective Medications

• Do not prescribe expectorants, mucolytics, or bronchodilators for acute URTI in primary care—these have no proven benefit. 2
• Avoid β-agonists (albuterol) unless the patient has underlying asthma or COPD. 1
• Do not use topical decongestants beyond 3-5 days to prevent rebound congestion. 1

Patient Education and Safety Netting

Set Realistic Expectations

• Counsel patients that viral URTI is self-limited and typically resolves within 10-14 days. 1
• Explain that discolored mucus is normal in viral URI and does not warrant antibiotics. 1

Provide Return Precautions

• Advise patients to return if symptoms persist beyond 3 weeks. 2
• Instruct patients to contact you if fever exceeds 4 days, dyspnea worsens, or consciousness decreases. 2
• Expect clinical improvement within 3 days of symptomatic treatment; if not observed, reevaluate. 6

Prevent Transmission

• Emphasize hand hygiene and respiratory etiquette to prevent spread. 1

Clinical Decision Algorithm

1. Confirm viral URTI diagnosis: Symptoms consistent with URTI, duration <3 weeks, absence of severe features (no high fever >4 days, no dyspnea, no focal chest signs). 2, 1

2. Rule out pneumonia: If pneumonia is suspected (new focal chest signs, dyspnea, tachypnea, fever >4 days), obtain chest radiograph. 2

3. Initiate symptomatic treatment:

   • Analgesics (acetaminophen, ibuprofen, or naproxen) for all patients 1
   • Dextromethorphan or codeine for bothersome dry cough 2, 4
   • Optional: nasal saline, oral decongestants, first-generation antihistamine-decongestant combinations 1

4. Avoid antibiotics entirely unless clear evidence of bacterial superinfection (symptoms >10 days or worsening after 5-7 days). 1

Common Pitfalls to Avoid

• Do not mistake purulent discharge for bacterial infection—discolored mucus is normal in viral URI. 1
• Do not prescribe antibiotics for patient satisfaction—this increases antimicrobial resistance and causes harm without benefit. 1
• Do not use newer antihistamines—only first-generation antihistamines combined with decongestants have proven efficacy. 1
• Do not continue topical decongestants beyond 3-5 days—this leads to rebound congestion. 1