What is the management approach for a patient with a 6-day history of cough and coryza, indicative of an Upper Respiratory Tract Infection (URTI), without underlying conditions such as asthma, Chronic Obstructive Pulmonary Disease (COPD), or immunodeficiency?

Management of 6-Day URTI with Cough and Coryza

For a patient with 6 days of cough and coryza from an uncomplicated upper respiratory tract infection, provide symptomatic treatment only—no antibiotics, no routine cough suppressants, and focus on reassurance that symptoms typically resolve within 3 weeks. 1

Immediate Management Approach

Symptomatic Relief (First-Line)

• Recommend honey and lemon as the primary treatment, as it is as effective as pharmacological treatments for benign viral cough and costs nothing. 1
• Advise acetaminophen or ibuprofen for pain or fever relief if present. 2
• Antihistamines and decongestants can treat congestion and runny nose, but are not routinely necessary for uncomplicated viral URTIs. 2

What NOT to Prescribe

• Do not prescribe antibiotics—most URTIs are viral and self-limiting, and antibiotic treatment in uncomplicated acute bronchitis shows no benefit outweighing side effects. 3, 1
• Do not prescribe expectorants, mucolytics, antihistamines, or bronchodilators for acute LRTI in primary care, as consistent evidence for beneficial effects is lacking. 3
• Do not prescribe codeine or codeine-containing products, as they have no greater efficacy than dextromethorphan but significantly more adverse effects. 1

When Cough Suppressants May Be Considered

• Only consider dextromethorphan 30-60 mg for short-term use if the patient has a dry, bothersome cough that disturbs sleep—the standard OTC dose is subtherapeutic, and maximum cough reflex suppression occurs at 60 mg. 3, 1, 4
• Dextromethorphan showed some effect in patients with acute cough, whereas codeine studies failed to show beneficial effects. 3

Patient Education and Expectations

Timeline and Natural History

• Reassure the patient that 90% of viral URTIs resolve within 3 weeks, though cough can linger for 3-8 weeks after the initial infection as a postinfectious phenomenon. 1, 5
• At 6 days, the patient is still within the typical acute phase (less than 3 weeks), and symptoms should continue improving. 1, 5
• Approximately 10% of patients will continue coughing for more than 20-25 days even with appropriate management. 5

When to Return for Reassessment

• Advise the patient to return if cough persists beyond 3 weeks, as this warrants consideration of alternative diagnoses including pertussis, Mycoplasma/Chlamydophila pneumoniae, upper airway cough syndrome, or gastroesophageal reflux disease. 1, 5
• Return immediately if new concerning symptoms develop, such as high fever, severe dyspnea, chest pain, or systemic deterioration. 1
• If cough persists beyond 8 weeks, it becomes chronic cough requiring full diagnostic workup for asthma, chronic sinusitis, GERD, and other chronic pulmonary conditions. 5

Critical Red Flags to Assess

Rule Out Complications Requiring Antibiotics

While this patient has uncomplicated URTI, antibiotics would be indicated if any of the following were present:

• Suspected or definite pneumonia (fever, dyspnea, focal chest findings). 3
• Age >75 years with fever. 3
• Cardiac failure, insulin-dependent diabetes, or serious neurological disorder. 3
• Systemically very unwell or features suggestive of serious illness. 6

Consider Underlying Chronic Disease

• Assess for wheezing, prolonged expiration, smoking history, or allergy symptoms—up to 45% of patients with acute cough >2 weeks may have undiagnosed asthma or COPD. 3
• Lung function tests should be considered if at least two of these signs are present. 3
• Serious chronic diseases like asthma, COPD, cardiac failure, or diabetes tend to flare up during URTIs, and chronic medication dosages may need temporary adjustment. 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics reflexively—this contributes to antimicrobial resistance, and antibiotics are not indicated for uncomplicated viral URTIs. 1
• Do not use subtherapeutic doses of dextromethorphan if prescribing for severe dry cough—the effective dose is 30-60 mg, not the standard OTC dose. 1
• Do not dismiss the patient's expectations—most patients attending with acute URTI seek further assessment, information, and reassurance rather than antibiotics (only one in three expect antibiotics). 7
• Do not confuse upper and lower respiratory tract involvement—cough can be caused by URTIs, but patients with URTI can have LRTI simultaneously, requiring differentiation from pneumonia. 3