What is the recommended treatment and supportive care for an uncomplicated viral upper‑respiratory infection (common cold)?

Management of the Common Cold

For uncomplicated viral upper respiratory infection (common cold), do not prescribe antibiotics—they provide no benefit and cause harm—and instead use symptomatic treatment with combination first-generation antihistamine-decongestant products (such as brompheniramine plus pseudoephedrine) along with NSAIDs for pain and fever. 1, 2

Core Treatment Principles

What NOT to Do First

• Never prescribe antibiotics for uncomplicated common cold in adults or children 1, 2, 3
• Antibiotics do not shorten symptom duration, do not prevent complications even with risk factors present, and contribute to antimicrobial resistance 1, 2
• Purulent or discolored nasal discharge does NOT indicate bacterial infection—this is normal viral inflammation with neutrophils, not bacteria 2, 3

Symptomatic Treatment Algorithm

First-line therapy:

• Combination antihistamine-decongestant-analgesic products provide superior relief with approximately 1 in 4 patients experiencing significant improvement (odds ratio of treatment failure 0.47,95% CI 0.33-0.67) 2
• Specifically: first-generation antihistamine (brompheniramine or diphenhydramine) PLUS sustained-release pseudoephedrine reduces congestion, rhinorrhea, cough, and post-nasal drip 1, 2, 3
• Do NOT use newer "non-sedating" antihistamines alone—they are ineffective for common cold 1, 3

Analgesics for pain, fever, and systemic symptoms:

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours OR naproxen) are most effective—they reduce headache, ear pain, muscle/joint pain, malaise, sneezing, AND cough through anti-inflammatory mechanisms 1, 2
• Acetaminophen/paracetamol helps nasal obstruction and rhinorrhea but does not improve other symptoms as effectively 2
• In children: use acetaminophen/paracetamol for fever and pain 2

Nasal congestion management:

• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit 2, 3
• Topical nasal decongestants are effective BUT limit to 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa) 1, 2, 3
• Nasal saline irrigation provides modest relief, particularly beneficial in children 2, 3

For rhinorrhea specifically:

• Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve nasal congestion 1, 2

For cough:

• Dextromethorphan 60 mg suppresses acute cough (standard OTC doses are likely subtherapeutic) 2
• Honey (in children ≥1 year old) is recommended as simple, inexpensive home remedy 2
• Menthol inhalation provides acute but short-lived suppression 2
• Avoid opiate antitussives due to significant adverse effects without clear superiority 2

Adjunctive Therapy with Critical Timing

Zinc lozenges (≥75 mg/day using zinc acetate or zinc gluconate):

• Significantly reduce cold duration BUT ONLY if started within 24 hours of symptom onset 2
• No benefit if symptoms already established beyond 24 hours 2
• Potential side effects include bad taste and nausea 2

Patient Education and Expected Course

Natural history to communicate:

• Common cold is self-limited viral illness typically lasting 7-10 days 1, 2, 3
• Up to 25% of patients continue with cough and nasal discharge for up to 14 days—this is NORMAL and does NOT indicate bacterial infection 1, 2, 3
• Sore throat peaks early and resolves by day 3-4 2
• Fever and myalgia resolve within 5 days 2
• Nasal congestion and cough persist longer, commonly into second and third week 2

When to Suspect Bacterial Complication

Only consider antibiotics if bacterial complication develops (occurs in only 0.5-2% of viral URIs) 1, 2:

Red flags requiring reassessment:

• Fever >38°C (100.4°F) persisting beyond 3 days OR appearing after initial improvement 1, 2
• "Double sickening" pattern: initial improvement followed by worsening 2, 3
• Symptoms persisting >10 days WITHOUT any improvement 1, 2
• Severe unilateral facial pain 2
• Respiratory discomfort, irritability, nocturnal awakening 1
• Otalgia, otorrhea (suggesting acute otitis media) 1
• Purulent conjunctivitis, palpebral edema 1

Critical diagnostic pitfall to avoid:

• Do NOT diagnose bacterial sinusitis in the first 10 days of symptoms—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics 1, 2
• Radiographic sinus abnormalities have no clinical specificity for bacterial infection within the first week 1

Special Populations

Pregnant women:

• Acetaminophen/paracetamol is first-line for pain and fever 2

Children:

• Do NOT use over-the-counter cold medications in children younger than 4-6 years 1, 4, 5
• Safe and effective treatments: acetaminophen, honey (≥1 year old), nasal saline irrigation 2, 5

Common Clinical Pitfalls

• Pitfall #1: Prescribing antibiotics based on purulent nasal discharge—this reflects normal viral inflammation, not bacterial infection 2, 3
• Pitfall #2: Ordering sinus imaging during acute illness—abnormalities are expected and non-specific 1, 2
• Pitfall #3: Using prolonged topical decongestants beyond 5 days—causes rebound congestion 1, 2, 3
• Pitfall #4: Prescribing newer antihistamines alone—only first-generation antihistamines combined with decongestants have proven efficacy 1, 3