What is the recommended duration of sick leave for a patient with a viral upper respiratory tract infection or allergic reaction, presenting with fever and mild congestion that can be relieved by antihistamines such as diphenhydramine (generic name) or loratadine (generic name)?

Recommended Sick Leave Duration

Give 2 days of sick leave (Option A). The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends 2 days of sick leave for patients with fever and mild congestion from a viral upper respiratory infection, as symptoms typically peak within 3 days and most patients can return to work once fever subsides and symptoms are manageable with over-the-counter medications 1.

Clinical Rationale for 2-Day Sick Leave

The evidence-based approach to sick leave duration is structured around the natural history of viral upper respiratory infections:

• Viral upper respiratory infections are self-limited diseases where symptoms typically peak within 3 days, then gradually decline and resolve within 10 to 14 days 1.
• The presence of fever warrants at least brief work absence to prevent transmission to others and allow initial symptom control, with 2 days being sufficient for fever resolution and establishment of effective symptomatic management 1.
• Return to work is appropriate once fever resolves and symptoms are controlled with over-the-counter medications, typically by day 2-3 1.

Management During Sick Leave Period

During the 2-day sick leave period, focus on symptomatic management to enable functional capacity:

• Analgesics or antipyretic drugs (acetaminophen, ibuprofen) should be given for pain or fever, allowing functional capacity and return to work after 2 days 1.
• Nasal saline irrigation is recommended for symptomatic relief with low risk of adverse reactions 1.
• Oral decongestants may provide additional symptomatic relief if no contraindications exist (hypertension, anxiety) 1.

Critical Caveat About Antihistamine Use

Antihistamines are not recommended for treating viral rhinosinusitis in patients without allergic rhinitis, as they show no significant benefit for overall symptom improvement and may potentially worsen congestion by drying nasal mucosa 2. This is a common pitfall—just because the patient reports relief with antihistamines does not mean they are the appropriate treatment:

• Both studies evaluating antihistamines in rhinosinusitis showed no additive effect over standard treatment 2.
• Antihistamines may worsen congestion by drying the nasal mucosa in patients without allergic components 2.
• If antihistamines are providing relief, this suggests an allergic component to the symptoms, in which case second-generation antihistamines (loratadine, cetirizine) are preferred over first-generation options (diphenhydramine) due to reduced sedation 1.

Why Not One Week?

One week of sick leave (Option B) is excessive and not supported by guidelines for uncomplicated viral upper respiratory infections. The common cold is a benign, self-limited illness where patients should be advised that symptoms can last up to 2 weeks, but this does not require continuous work absence 3. Most patients achieve adequate symptom control within 2-3 days to resume normal activities 1.

Why Not Zero Days?

Option C (no sick leave) is inappropriate because the presence of fever warrants work absence to prevent transmission to others 1. Additionally, the initial 2 days allow for establishment of effective symptomatic management and confirmation that the illness follows an expected benign course 3.

Follow-Up Instructions

Patients should be advised to follow up with the clinician if symptoms worsen or exceed the expected time of recovery (10-14 days) 3. Red flags requiring earlier reassessment include:

• Persistent symptoms for more than 10 days 3
• Onset of severe symptoms with high fever (>39°C) and purulent nasal discharge or facial pain lasting at least 3 consecutive days 3
• Worsening symptoms following initial improvement (double sickening) 3