What medications should be given to a patient with a viral upper respiratory tract infection (URI) characterized by cough, fever, and runny nose, without signs of bacterial infection?

Treatment of Viral Upper Respiratory Tract Infection

For a patient with viral URI presenting with cough, fever, and runny nose without bacterial infection signs, provide symptomatic relief only—antibiotics are not indicated and should never be prescribed. 1, 2

First-Line Symptomatic Medications

Analgesics/Antipyretics for Pain and Fever

• Acetaminophen or ibuprofen should be given for pain relief and fever control, as these are the primary reasons patients seek care and represent the most important symptomatic intervention. 1, 2, 3, 4
• Dosing: Acetaminophen 650 mg orally as needed, or ibuprofen 400-600 mg orally as needed for adults. 3, 4

Nasal Saline Irrigation

• Nasal saline irrigation (physiologic or hypertonic) provides symptomatic relief with minimal adverse effects and should be recommended for all patients. 1, 2
• This helps cleanse nasal passages and relieve congestion through a mechanical effect. 1

Second-Line Symptomatic Options

Oral Decongestants

• Oral decongestants (pseudoephedrine) may provide symptomatic relief but must be avoided in patients with hypertension, anxiety, cardiac arrhythmia, or glaucoma. 1, 2
• These work by reducing nasal congestion but do not prevent bacterial complications. 1

Topical Nasal Decongestants

• Topical decongestants may be used but MUST be limited to 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa). 1, 2
• This is a critical pitfall—prolonged use causes worse symptoms than the original illness. 1

Topical Intranasal Corticosteroids

• Intranasal steroids provide modest benefit (73% improvement vs 66% with placebo at 14-21 days, number needed to treat = 14) with rare adverse events. 1
• This represents a small but real benefit that may justify use based on patient preference. 1

Medications with Limited or No Evidence

Antihistamines

• First-generation antihistamines may provide relief of excessive secretions and sneezing through a drying effect, though clinical evidence specifically for viral URI is lacking. 1, 2
• Newer non-sedating antihistamines are relatively ineffective for common cold symptoms. 2
• Patients must be counseled about potential adverse effects (sedation, dry mouth). 2

Cough Suppressants and Expectorants

• Dextromethorphan (cough suppressant) and guaifenesin (expectorant) are commonly used but lack evidence of clinical efficacy—their use is based on patient and provider preference only. 1, 5

What NOT to Prescribe

Antibiotics

• Antibiotics are completely ineffective for viral illness, provide no symptom relief, and should NEVER be prescribed. 1, 2
• Antibiotic use causes avoidable adverse events, drives antimicrobial resistance, and increases healthcare costs without benefit. 1, 2
• The color of nasal discharge (yellow or green) does NOT indicate bacterial infection—it reflects neutrophil presence, not bacteria. 1, 6

Systemic Corticosteroids

• Oral/systemic corticosteroids have not been shown effective for viral rhinitis and should not be used. 2

Critical Clinical Pitfalls to Avoid

Do not prescribe antibiotics based on:

• Colored (yellow/green) nasal discharge alone 1, 6
• Duration of symptoms less than 10 days 6, 7
• Presence of cough and congestion without other bacterial indicators 6

Bacterial infection should only be suspected when:

• Symptoms persist ≥10 days without improvement, OR 6, 7
• "Double worsening" occurs (initial improvement followed by worsening at 5-7 days), OR 6, 7
• Severe onset with high fever (>39°C) and purulent discharge for ≥3 consecutive days 6, 7

Special Populations

Children Under 3 Years

• Avoid decongestants and antihistamines in children under 3 years due to potential adverse effects. 2, 7

Patients with Chronic Conditions

• Monitor patients with asthma or other chronic respiratory conditions more closely for symptom progression. 2

Patient Education Points

• Viral URI symptoms typically peak within 3 days and resolve within 10-14 days. 1, 7
• Nasal discharge commonly changes from clear to purulent to clear during normal viral resolution—this does not require antibiotics. 6
• Adequate hydration and rest support recovery. 2, 7
• Seek reevaluation if fever persists >3 days, symptoms worsen after initial improvement, or symptoms persist >10 days without improvement. 7