Prescription for Viral Upper Respiratory Infection
Do not prescribe antibiotics—this patient has a viral upper respiratory infection that requires only symptomatic treatment with over-the-counter medications. 1, 2
What This Patient Has
This presentation of fever, non-productive cough, and runny nose is a classic viral upper respiratory infection (common cold/acute bronchitis), which accounts for over 90% of acute cough illnesses in otherwise healthy adults. 1 The non-productive cough and rhinorrhea without focal chest findings, tachycardia (>100 bpm), tachypnea (>24 breaths/min), or abnormal lung examination effectively rules out pneumonia. 1
The Prescription: Symptomatic Treatment Only
Write prescriptions or recommend the following:
For Fever and General Discomfort
- Ibuprofen 400-600 mg every 6-8 hours as needed (or naproxen 220-440 mg every 8-12 hours, or acetaminophen 500-1000 mg every 6 hours) 1, 2, 3
For Nasal Congestion and Runny Nose
- First-generation antihistamine/decongestant combination (e.g., diphenhydramine 25-50 mg + pseudoephedrine 60 mg, three times daily) 1, 2
For Cough Suppression (if bothersome)
- Dextromethorphan 60 mg every 6-8 hours as needed 1
- Most over-the-counter preparations contain subtherapeutic doses; maximum cough suppression occurs at 60 mg 1
Adjunctive Non-Prescription Measures
- Nasal saline irrigation (safe with low adverse effects, provides minor but consistent symptom improvement) 2, 3
- Simple home remedies like honey and lemon may provide symptomatic relief 1
What NOT to Prescribe
Absolutely avoid antibiotics. 1, 2, 3 More than 90% of acute cough illnesses in healthy adults are viral, and antibiotics provide zero benefit while causing harm (adverse effects occur in 1 in 8 patients treated). 1 Even when patients have purulent or discolored nasal discharge, this does NOT indicate bacterial infection—it simply reflects inflammatory cells and sloughed epithelial cells, not bacteria. 1, 2
Do not prescribe:
- Antibiotics (azithromycin, amoxicillin, etc.) 1, 2
- Beta-agonists like albuterol (ineffective unless patient has underlying asthma or COPD) 1, 2
- Newer non-sedating antihistamines alone (ineffective for acute viral URI) 1, 2
- Codeine or pholcodine (greater adverse effects than dextromethorphan without added benefit) 1
Patient Education and Safety Netting
Counsel the patient that:
- This is a self-limited viral illness that typically peaks within 3 days and resolves within 10-14 days without antibiotics 2, 3
- Discolored mucus is normal and does NOT mean bacterial infection 1, 2
- Hand hygiene and respiratory etiquette prevent transmission 3
Provide return precautions—patient should return if:
- Symptoms persist beyond 10 days without improvement 2, 3
- Symptoms worsen after 5-7 days (suggesting bacterial superinfection) 2, 3
- Development of high fever (>39°C), severe shortness of breath, chest pain, or focal chest findings 1, 3
Common Pitfalls to Avoid
Do not mistake purulent discharge for bacterial infection. Discolored nasal secretions are present in uncomplicated viral infections and do not warrant antibiotics. 1, 2 This is the single most common reason for inappropriate antibiotic prescribing in viral URI. 1
Do not prescribe antibiotics "just in case" or for patient satisfaction. This increases antimicrobial resistance and causes direct harm to the patient without any benefit. 1, 2, 3
Warn about topical decongestant overuse. If recommending nasal decongestant sprays, limit use to 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa). 2, 3
Recognize that first-generation antihistamines cause sedation. Warn patients about drowsiness, dry mouth, and urinary retention, and use caution in elderly patients due to anticholinergic effects. 3