What is the appropriate treatment for an otherwise healthy adult with an uncomplicated common cold?

Treatment of the Common Cold

The common cold requires only symptomatic management with combination antihistamine-decongestant-analgesic products providing the most effective relief—antibiotics are never indicated and provide no benefit while causing harm. 1, 2

What NOT to Do (Critical)

• Never prescribe antibiotics for uncomplicated common cold 1, 2

  • Antibiotics do not reduce symptom duration, do not prevent complications (sinusitis, otitis media, asthma exacerbation), and cause more harm than benefit 1
  • Number needed to harm from antibiotics is 8, while number needed to treat is 18—meaning you harm more patients than you help 1
  • Antibiotics contribute to antimicrobial resistance without clinical benefit 1, 2

• Do not use intranasal corticosteroids for acute cold symptoms—they are ineffective 2, 3

• Do not use non-sedating (newer generation) antihistamines—they provide no benefit 2

First-Line Symptomatic Treatment

Use combination antihistamine-decongestant-analgesic products as they provide superior symptom relief compared to single agents, with 1 in 4 patients experiencing significant improvement (NNT 5.6). 2, 4

Specific Effective Combinations:

• First-generation antihistamine (brompheniramine or chlorphenamine) + sustained-release pseudoephedrine + analgesic (paracetamol or ibuprofen) 2, 4
• This combination significantly reduces congestion, rhinorrhea, pain, and overall symptom burden 2, 4

Individual Symptomatic Agents:

For pain, fever, and systemic symptoms:

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are highly effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 2, 5
• Acetaminophen/paracetamol (1000 mg every 4-6 hours, max 4000 mg/24 hours) helps with nasal obstruction and rhinorrhea but does not improve other symptoms as effectively as NSAIDs 2, 5
• Paracetamol is preferred in pregnancy and patients with contraindications to NSAIDs 5

For nasal congestion:

• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit 2, 6
• Topical nasal decongestants (oxymetazoline) are effective but limit use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 2, 5

For rhinorrhea:

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

For cough:

• Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard OTC doses are likely subtherapeutic 2
• Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit 2, 6
• Avoid opiate antitussives due to significant adverse effects without clear superiority 2
• Menthol inhalation provides acute but short-lived cough suppression 2

Adjunctive therapy:

• Nasal saline irrigation provides modest symptom relief by facilitating clearance of secretions, particularly beneficial in children 2, 5, 6

Evidence-Based Adjunctive Therapy (Time-Sensitive)

Zinc lozenges (≥75 mg/day as zinc acetate or zinc gluconate) significantly reduce cold duration BUT only if started within 24 hours of symptom onset. 2, 6

• Critical timing: No benefit if symptoms already established beyond 24 hours 2
• Potential side effects include bad taste and nausea 2, 6
• This is the only intervention that actually shortens illness duration when used appropriately 2, 6

Pediatric-Specific Considerations

• Do not use over-the-counter cough and cold medications in children younger than 4 years due to potential harm and no proven benefits 6
• Acetaminophen/paracetamol for fever and pain is appropriate 2, 5
• Vapor rub, buckwheat honey (age >1 year), and nasal saline irrigation are safe and effective options 6

Expected Clinical Course and When to Reassess

Educate patients that cold symptoms typically last 7-10 days, with up to 25% experiencing symptoms for 14 days—this is normal and does not indicate bacterial infection. 1, 2

Normal symptom timeline:

• Sore throat peaks early and resolves by day 3-4 2
• Fever and myalgia resolve within 5 days 2
• Nasal congestion and cough commonly continue into the second and third week 2

Red flags requiring reassessment:

• Symptoms persisting >10 days without any improvement 1, 2, 5
• High fever ≥39°C (102.2°F) with purulent nasal discharge or facial pain for ≥3-4 consecutive days 1, 2, 5
• "Double sickening" pattern: initial improvement followed by worsening after 5 days (suggests bacterial superinfection) 1, 2, 5
• Hemoptysis (any amount warrants chest radiograph) 2
• Severe unilateral facial pain 2
• Acute breathlessness 2

Common 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, and purulent nasal discharge is a normal feature of viral colds, not an indication for antibiotics. 1, 2, 5

Prevention and Transmission

• Hand hygiene with soap and water is the single most effective prevention measure as the common cold spreads primarily through direct hand contact with contaminated surfaces 7
• Patients are most contagious during the first 3 days of illness but can shed virus for 5-10 days (longer in children and immunocompromised patients) 7
• Advise patients to stay home during the first 3-5 days when most contagious 7