What is the recommended treatment for fever accompanying a common cold, and what red‑flag symptoms require urgent evaluation?

Treatment of Fever in Common Cold

Fever accompanying a common cold should be treated with antipyretics (acetaminophen or ibuprofen) for symptomatic relief only—antibiotics are never indicated for uncomplicated colds, and most fevers resolve within 3-5 days without intervention. 1, 2

Symptomatic Management of Fever

For fever and associated symptoms, use the following approach:

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are highly effective for fever, headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 2
• Acetaminophen/paracetamol helps with fever and may also reduce nasal obstruction and rhinorrhea 2
• Combination antihistamine-decongestant-analgesic products provide superior symptom relief compared to single agents, with approximately 1 in 4 patients experiencing significant improvement (odds ratio of treatment failure 0.47; number needed to treat 5.6) 2

Antibiotics have absolutely no role in treating uncomplicated common cold with fever—they do not shorten symptom duration, do not prevent complications, and contribute to antimicrobial resistance 1

Red-Flag Symptoms Requiring Urgent Evaluation

Seek immediate medical evaluation if any of the following are present:

• 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 symptoms, suggesting bacterial superinfection 1, 2, 3
• Severe unilateral facial pain suggesting bacterial sinusitis 2, 3
• Hemoptysis (any amount warrants chest radiograph and possible bronchoscopy) 2
• Acute breathlessness requiring assessment for asthma or anaphylaxis 2
• Respiratory distress 1
• Purulent conjunctivitis with palpebral edema 1
• Otalgia or otorrhea suggesting acute otitis media 1
• Gastrointestinal symptoms (anorexia, vomiting, diarrhea) 1

Expected Clinical Course

Normal fever patterns in common cold:

• Fever and myalgia typically resolve within 5 days 2
• Sore throat peaks early and resolves by day 3-4 2
• Overall cold symptoms last 7-10 days, though up to 25% of patients have symptoms for 14 days 1, 2, 3
• Nasal congestion and cough commonly persist into the second and third week 2

Critical pitfall: Parents often have "fever phobia" and treat aggressively even with low-grade temperatures below 38.9°C, but moderate fever (≤40°C) does not cause neurological damage 4. Reassure patients that fever is part of the normal viral response 1.

When to Consider Bacterial Complications

Only suspect bacterial infection requiring antibiotics if at least 3 of these 5 criteria are present:

• Discolored (purulent) nasal discharge 2, 3
• Severe local facial pain 2, 3
• Fever >38°C (100.4°F) 2, 3
• "Double sickening" pattern 2, 3
• Elevated inflammatory markers 2, 3

Important context: Only 0.5-2% of viral upper respiratory infections develop bacterial complications 2, 3. Colored nasal discharge alone does NOT indicate bacterial infection—it is a normal part of the viral cold course 2.

Pediatric-Specific Considerations

• Acetaminophen/paracetamol is first-line for fever and pain in children 2
• Fever is common in children during the first 3 days of a cold 5
• Avoid over-the-counter cough and cold medications in children younger than 4 years due to potential harm without benefit 6

Patient Education Points

• The common cold is viral and self-limiting—antibiotics will not help and may cause harm 1
• Fever is part of the body's normal response to viral infection 1
• Symptoms can last up to 2 weeks in 25% of cases—this is normal and does not indicate bacterial infection 1, 2, 3
• Follow up if fever persists beyond 3 days or if any red-flag symptoms develop 1, 2