What is the appropriate outpatient prescription for an adult with dry cough, fever, and rhinorrhea due to an acute viral upper respiratory infection, assuming no drug allergies or significant comorbidities?

Management of Acute Viral Upper Respiratory Infection

Do not prescribe antibiotics for this patient—this is a viral upper respiratory infection (common cold) that requires only symptomatic treatment. 1

Why Antibiotics Should Not Be Prescribed

• Antibiotics are not effective for viral URIs and lead to significantly increased risk for adverse effects without providing benefit. 1
• The vast majority (>80-90%) of acute URIs presenting with dry cough, fever, and runny nose are caused by viruses (rhinoviruses, coronaviruses, parainfluenza, RSV, adenoviruses). 2
• Antibiotics play no role in preventing complications of the common cold such as bacterial sinusitis, asthma exacerbation, or otitis media. 1
• Purulent nasal discharge does not predict bacterial infection and does not justify antibiotic use. 2

What You Should Prescribe for Symptomatic Relief

Combination antihistamine-analgesic-decongestant products provide significant symptom relief in 1 out of 4 patients treated. 1

Specific Symptomatic Treatment Options:

• First-generation antihistamine/decongestant combination (preferred over newer non-sedating antihistamines which are ineffective for URI cough) 3
• Naproxen 220-440 mg twice daily for pain, fever, and inflammation 3
• Acetaminophen or ibuprofen for fever and pain relief 1
• Antitussives (dextromethorphan or codeine) for bothersome dry cough 1
• Inhaled ipratropium bromide for rhinorrhea 1
• Zinc supplements (if within 24 hours of symptom onset) may reduce duration, though weigh against adverse effects like nausea and bad taste 1

Treatments to AVOID:

• Do NOT prescribe expectorants, mucolytics, or bronchodilators—these are not effective for acute LRTI in primary care. 1
• Do NOT recommend vitamin C or echinacea—no evidence supports their use. 1

Patient Education and Follow-Up Instructions

Advise the patient that symptoms typically last up to 2 weeks and this is normal for a viral infection. 1, 2

When to Return for Re-evaluation:

• Symptoms persist beyond 10 days without any improvement (suggests possible bacterial rhinosinusitis) 1, 2
• "Double sickening"—worsening after initial improvement at days 5-7 (suggests bacterial superinfection) 1, 2
• High fever >39°C with purulent nasal discharge for ≥3 consecutive days (suggests bacterial infection) 1
• Severe unilateral facial pain with facial swelling 3

Common Pitfall to Avoid

Patient satisfaction depends more on spending adequate time explaining the illness and providing a symptomatic treatment plan than on receiving an antibiotic prescription. 1 Use a symptomatic prescription pad to provide written recommendations for symptom management—this allows patients to leave with an actionable plan and increases satisfaction while avoiding unnecessary antibiotics. 1