Are antiviral drugs indicated for a patient with an acute viral upper‑respiratory infection (common cold) presenting with fever, and when should antiviral therapy be used?

Antiviral Drugs for Common Cold with Fever

Antiviral drugs are NOT indicated for the common cold, even when fever is present, because the common cold is self-limiting and antivirals have no proven benefit for this condition. 1, 2

Key Clinical Distinction: Common Cold vs. Influenza

The critical decision point is determining whether the patient has a common cold or influenza, as this fundamentally changes management:

Common Cold (No Antivirals Indicated)

• Caused by >200 different viruses (rhinoviruses, coronaviruses, parainfluenza, RSV, adenoviruses) 1
• Specific antiviral therapies have shown limited efficacy due to the myriad of potential viral causes and side effects 1
• Self-limiting illness lasting 7-10 days (up to 14 days in 25% of patients) 2
• Treatment is purely symptomatic 2

Influenza (Antivirals ARE Indicated)

Antivirals should ONLY be prescribed if ALL three criteria are met: 1

1. Acute influenza-like illness (sudden onset with systemic symptoms)
2. Fever >38°C (100.4°F)
3. Symptomatic for ≤48 hours

Treatment regimen: Oseltamivir 75 mg every 12 hours for 5 days 1

Important Exceptions to the 48-Hour Rule

• Immunocompromised or very elderly patients who cannot mount adequate febrile response may still be eligible for antivirals despite lack of documented fever 1
• Severely ill hospitalized patients, particularly if immunocompromised, may benefit from antivirals started >48 hours from onset, though evidence is lacking 1

Evidence-Based Symptomatic Management for Common Cold

Since antivirals are not indicated for common cold, focus on effective symptomatic treatment:

Most Effective Treatments

• First-generation antihistamine/decongestant combinations (brompheniramine + sustained-release pseudoephedrine) reduce cough, postnasal drip, and throat clearing 1, 2
• NSAIDs (naproxen, ibuprofen 400-800 mg every 6-8 hours) decrease cough, headache, malaise, myalgia, and sneezing 1, 2

Ineffective Treatments to Avoid

• Newer generation "non-sedating" antihistamines are ineffective and should not be used 1
• Antibiotics have no benefit for uncomplicated common cold and contribute to antimicrobial resistance 2, 3, 4

Critical Clinical Pitfall

Do NOT diagnose bacterial sinusitis during the first 7-10 days of symptoms 1, 2. Approximately 87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics, and 79% show resolution by days 13-20 without treatment 1.

When to Reconsider: Red Flags Suggesting Influenza or Complications

• Fever >38°C persisting beyond 3 days or appearing after initial improvement 2
• "Double sickening" pattern (initial improvement followed by worsening) 2
• Acute breathlessness 2
• Severe systemic symptoms with sudden onset during influenza season 1

Bottom Line Algorithm

1. Is it influenza season AND patient meets all 3 criteria (ILI + fever >38°C + ≤48 hours)?

   • YES → Oseltamivir 75 mg BID × 5 days 1
   • NO → Proceed to step 2

2. Is it common cold (gradual onset, primarily nasal/throat symptoms)?

   • YES → NO antivirals; use symptomatic treatment only 1, 2
   • Combination antihistamine/decongestant + NSAIDs 1, 2

3. Special populations (immunocompromised, very elderly, severely ill)?

   • Consider antivirals even outside typical criteria 1