Management of Acute Nasopharyngitis
Do not prescribe antibiotics for acute nasopharyngitis—provide symptomatic treatment only with acetaminophen or NSAIDs, as this is a self-limited viral illness that resolves without antibiotics. 1
Confirm the Diagnosis
Acute nasopharyngitis (the common cold) presents with rhinorrhea, nasal congestion, sneezing, sore throat, cough, low-grade fever, headache, and malaise. 1 The presence of rhinorrhea, cough, oral ulcers, and/or hoarseness strongly suggests viral etiology and argues against bacterial infection. 1 Patients with symptoms for fewer than 7 days are unlikely to have bacterial infection and do not require antibiotics. 1
First-Line Symptomatic Treatment
Prescribe acetaminophen 1000 mg every 4-6 hours (maximum 4000 mg/24 hours) as the preferred first-line agent for pain relief and fever control. 1 Acetaminophen has superior safety compared to NSAIDs—no gastrointestinal bleeding risk, no adverse renal effects, and no cardiovascular toxicity. 1
Alternatively, NSAIDs (ibuprofen) can be used for pain relief and fever control if acetaminophen is contraindicated. 1
Nasal saline irrigation provides cleansing and modest symptom relief by facilitating clearance of nasal secretions. 1
Additional Symptomatic Options
For significant symptoms, combination antihistamine-analgesic-decongestant products provide relief in 1 out of 4 patients treated. 1 However, research shows that acetaminophen alone is as effective as combination products containing acetaminophen, decongestant, and antihistamines for relieving symptoms in children. 2
Zinc supplements (≥75 mg/day as acetate or gluconate lozenges) started within 24 hours of symptom onset may reduce duration, but weigh benefits against adverse effects (nausea, bad taste). 1
Nasal decongestants (e.g., oxymetazoline) may be used for severe nasal congestion, but limit to 3 days maximum to avoid rhinitis medicamentosa. 1
What NOT to Do
Never prescribe antibiotics for acute nasopharyngitis—they are ineffective against viral infections, provide no benefit, and lead to significantly increased risk of adverse effects. 1 Antibiotics do not prevent complications such as bacterial sinusitis, asthma exacerbation, or otitis media. 1 Even when bacterial pathogens are present in the nasopharynx, the illness resolves without antibiotics. 1, 3
Do not prescribe antibiotics based on purulent nasal discharge alone—this is a normal feature of viral colds. 1
Do not use intranasal corticosteroids for common cold symptomatic relief (no evidence of benefit). 1
Avoid decongestants and antihistamines in children under 3 years due to possible adverse effects. 1
Vitamin C and echinacea have no proven benefit. 1
Patient Education and Expected Course
Symptoms of acute nasopharyngitis typically last up to 2 weeks and are self-limited. 1 Counsel patients that paracetamol treats the discomfort and fever but does not shorten illness duration. 1
Hand hygiene is the most effective method to reduce transmission. 1
When to Reassess or Escalate Care
Reassess patients with symptoms persisting ≥10 days without improvement, high fever ≥39°C with purulent nasal discharge or facial pain for ≥3-4 consecutive days, or worsening symptoms after initial improvement. 1 These patterns suggest possible secondary bacterial infection (acute bacterial rhinosinusitis) requiring different management. 1
Consider antibiotics only if clear evidence of secondary bacterial infection develops, such as acute bacterial rhinosinusitis meeting specific criteria. 1
Common Pitfall
The most common error is prescribing antibiotics for viral nasopharyngitis. Studies show 16% of nasopharyngitis visits in France resulted in antibiotic prescriptions (primarily amoxicillin), despite antibiotics being contraindicated for this viral condition. 4 This practice contributes to antimicrobial resistance without providing clinical benefit. 1, 4