No Antibiotics Indicated
Do not start antibiotics for this patient—the presence of runny nose with normal vital signs and absence of crackles strongly indicates a viral upper respiratory tract infection that will not benefit from antibiotic therapy. 1
Clinical Reasoning
The clinical presentation argues decisively against bacterial pneumonia:
The presence of runny nose (rhinorrhea) significantly decreases the likelihood of pneumonia 1. The American College of Chest Physicians specifically notes that "the absence of runny nose" combined with breathlessness and crackles is what suggests pneumonia—this patient has the opposite presentation. 1
Normal vital signs and absence of crackles on lung examination rule out pneumonia as a diagnosis requiring antibiotics 1. The CHEST guidelines explicitly state: "For outpatient adults with acute cough and no clinical or radiographic evidence of pneumonia (e.g., when vital signs and lung exams are normal) we do not suggest the routine use of antibiotics." 1
This clinical picture is consistent with a viral upper respiratory tract infection (common cold), which accounts for the vast majority of acute respiratory infections and does not require antimicrobial therapy 2, 3, 4.
Key Distinguishing Features of Pneumonia (All Absent Here)
Pneumonia would require the following features, which this patient lacks:
- Abnormal lung examination: Crackles, diminished breath sounds, or other localizing chest signs 1, 5
- Abnormal vital signs: Fever ≥38°C, tachypnea, or tachycardia 1
- Absence of upper respiratory symptoms: Specifically, lack of runny nose increases pneumonia likelihood 1
- Dyspnea or breathlessness: A key symptom distinguishing lower from upper respiratory tract infection 1
Appropriate Management
Provide symptomatic treatment only:
- Analgesics (acetaminophen, ibuprofen, or naproxen) for fever and discomfort 1, 4
- Reassurance that symptoms typically resolve within 7-10 days 1, 3
- Advise return if symptoms worsen, persist beyond 10 days, or if new symptoms develop (high fever, dyspnea, chest pain) 1
Critical Pitfall to Avoid
Do not prescribe antibiotics based solely on fever and cough when rhinorrhea is present and lung examination is normal. This represents overuse of antibiotics for viral URIs, which increases antibiotic resistance, exposes patients to unnecessary adverse effects (number needed to harm = 8), and reinforces inappropriate expectations for future visits. 1, 6, 7
The American College of Physicians and CDC explicitly advise against routine antibiotic use for acute respiratory tract infections when clinical features suggest viral etiology. 1