What is the recommended treatment for a patient with a viral upper respiratory infection (URI)?

Treatment of Viral Upper Respiratory Infection

Viral URIs require supportive care only—antibiotics should never be prescribed as they provide no benefit, cause harm, and drive antibiotic resistance. 1

Recommended Supportive Treatment

Core Management Strategies

• Adequate hydration is the cornerstone of supportive care 1
• Age-appropriate antipyretics (acetaminophen or ibuprofen) for fever and pain relief 1, 2
• Rest and maintaining comfortable humidity levels in the home 1
• Proper hand hygiene to prevent transmission to others 1

Symptom-Specific Interventions

• Saline nasal irrigation may provide symptom relief and potentially faster recovery, with moderate evidence quality 1
• Antihistamines and/or decongestants may be used for congestion and runny nose in appropriate age groups 2
• Avoid decongestants and antihistamines in children under 3 years due to potential adverse effects 1

What NOT to Prescribe

Antibiotics

• Antibiotics are contraindicated for viral URIs—they provide zero benefit while causing avoidable drug-related adverse events, increasing antibiotic resistance, and raising risk of C. difficile colitis 1

Cough Suppressants

• Central cough suppressants (codeine, dextromethorphan) have limited efficacy for URI-related cough and are not recommended 3
• Peripheral cough suppressants also have limited efficacy for URI and are not recommended 3
• Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until proven effective in randomized controlled trials 3
• Albuterol is not recommended for cough not due to asthma 3

Other Ineffective Treatments

• Zinc preparations are not recommended for acute cough due to common cold 3
• Agents that alter mucus characteristics are not recommended for cough suppression 3

Expected Clinical Course

Normal Timeline

• Duration: 5-7 days with symptoms peaking around days 3-6 1
• Fever: Typically occurs early and resolves within 24-48 hours 1
• Nasal discharge: Starts clear and watery, becomes thicker and possibly purulent for several days (this is normal), then returns to clear before resolving 1
• Cough and congestion: Most persistent symptoms, commonly lasting 10+ days in uncomplicated viral infections 4

Critical Pitfall to Avoid

• Yellow or green nasal discharge does NOT indicate bacterial infection—this color change is normal during viral URIs due to neutrophil influx and is part of typical viral illness progression 4

When Antibiotics ARE Indicated (Bacterial Superinfection)

Suspect acute bacterial rhinosinusitis requiring antibiotics only when one of these three specific patterns occurs:

Pattern 1: Persistent Symptoms

• URI symptoms lasting ≥10 days without any improvement 1, 4
• This is the most common presentation requiring antibiotics 4

Pattern 2: Worsening/Biphasic Course ("Double Worsening")

• Initial improvement followed by worsening or new onset of fever, cough, or nasal discharge after 5-7 days 4
• Suggests bacterial superinfection 4

Pattern 3: Severe Onset

• High fever (>39°C) AND purulent nasal discharge for at least 3-4 consecutive days with the patient appearing ill 1, 4

Red Flags Requiring Medical Attention

Patients should seek further evaluation for:

• Persistent high fever for more than 3 days 1
• Worsening symptoms after initial improvement 1
• Symptoms persisting beyond 10 days without improvement 1
• Signs of respiratory distress 1
• Severe symptoms including concurrent high fever and purulent nasal discharge for the first 3-4 days 1

Prevention Strategies

• Proper hand hygiene 1
• Cough and sneeze etiquette (covering mouth and nose with elbow or tissue) 1
• Avoiding close contact with sick individuals when possible 1
• Age-appropriate vaccinations up to date 1
• Tap water gargling (20 mL for 15 seconds, 3 times consecutively, at least 3 times per day) was associated with URI prevention in one study (incidence rate ratio 0.64) 3

Key Clinical Pitfalls

• Never prescribe antibiotics based solely on: yellow/green nasal discharge color, presence of cough and congestion alone, or duration <10 days without worsening 4
• Do not obtain imaging studies to distinguish viral URI from bacterial sinusitis 1
• Do not rely on nasal discharge color to distinguish viral from bacterial infections 1