What is the appropriate treatment for an otherwise healthy adult with an acute upper‑respiratory infection presenting with cough with sputum, chills, and hoarseness?

Treatment of Acute Upper Respiratory Infection with Cough, Phlegm, Chills, and Hoarseness

For an otherwise healthy adult with these symptoms, antibiotics should NOT be prescribed, as this presentation is consistent with a viral upper respiratory infection that will resolve spontaneously within 10-14 days with symptomatic treatment only. 1, 2

Confirming This is NOT Pneumonia

Before proceeding with symptomatic treatment, you must exclude pneumonia by checking for these specific criteria 1:

• Heart rate >100 beats/min 1
• Respiratory rate >24 breaths/min 1
• Fever >38°C (100.4°F) 1
• Abnormal chest examination findings (rales, egophony, tactile fremitus) 1

If ALL four criteria are absent, pneumonia is highly unlikely and chest radiography is not needed. 1 If any are present, obtain a chest radiograph before proceeding. 1

Why Antibiotics Are Contraindicated

Antibiotics provide zero benefit for viral upper respiratory infections and cause more harm than good, with a number needed to harm of only 8 patients versus a number needed to treat of 18 for any marginal benefit. 2 The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that antibiotics should not be routinely prescribed for hoarseness. 1 Similarly, the American College of Physicians and CDC strongly recommend against antibiotic use for acute bronchitis. 1

The presence of colored (green or yellow) phlegm does NOT indicate bacterial infection—this is simply due to neutrophil influx during normal viral infection progression. 1, 2 This is a critical pitfall that leads to inappropriate antibiotic prescribing.

Symptomatic Treatment Algorithm

For Cough Management

First-line therapy: 1, 2

• Dextromethorphan 60 mg provides maximum cough suppression with fewer side effects than codeine 2
• Alternatively, codeine can be prescribed for dry, bothersome cough 1
• Inhaled ipratropium bromide (2-3 puffs four times daily) is highly effective for post-infectious cough 2, 3

Avoid these medications: 1

• Expectorants, mucolytics, antihistamines (when used alone), and bronchodilators should NOT be prescribed for acute respiratory infections in primary care 1

For Nasal Congestion and Rhinorrhea

Combination antihistamine-decongestant products provide significant symptom relief in 1 out of 4 patients 2:

• Brompheniramine/pseudoephedrine 2
• Chlorpheniramine/phenylephrine 2

Nasal saline irrigation can provide additional symptom relief 2

Important caveat: Do not use nasal decongestant sprays for more than 3-5 days due to rebound congestion risk. 2

For Chills and General Discomfort

Analgesics for symptom relief: 2

• Acetaminophen or ibuprofen for discomfort and fever 2

For Hoarseness

Voice rest and supportive measures: 1, 2

• Simple supportive measures including honey and lemon, adequate hydration, and voice rest 2
• Do NOT prescribe oral or inhaled steroids for hoarseness, as there is no evidence of benefit and significant potential for harm 1

Expected Timeline and Follow-Up

Symptoms typically persist for 10-14 days, with some cases lasting up to 2-3 weeks. 2 This is normal for viral infections and does not indicate treatment failure.

Instruct the patient to return if: 1

• Symptoms persist beyond 3 weeks 1
• No improvement within 3 days if antibiotics were prescribed (though they should not be in this case) 1
• Fever exceeds 4 days 1
• Dyspnea worsens 1

If cough persists beyond 8 weeks, reclassify as chronic cough and initiate systematic evaluation starting with treatment for upper airway cough syndrome. 3

Special Consideration: Influenza

If this presentation occurs during known influenza season and the patient has had symptoms for <48 hours with typical influenza features (fever, muscle ache, general malaise), consider antiviral treatment (neuraminidase inhibitors per CDC guidelines). 1 However, empirical antiviral treatment is generally not recommended outside of high-risk patients during confirmed influenza epidemics. 1

Critical Pitfalls to Avoid

• Never assume colored phlegm indicates bacterial infection—this leads to inappropriate antibiotic use 1, 2
• Never prescribe antibiotics for viral URI or acute bronchitis, as this contributes to antimicrobial resistance and causes adverse effects including allergic reactions and C. difficile infection 2
• Never prescribe steroids empirically for hoarseness, as there is no supporting evidence and significant potential for harm 1
• Do not prescribe expectorants, mucolytics, or bronchodilators for acute respiratory infections in primary care 1