Treatment of Fever and Cough in Adults
For adults with fever and cough from the common cold or acute bronchitis, use first-generation antihistamine/decongestant combinations (such as brompheniramine with pseudoephedrine) or naproxen 500 mg twice daily for cough, and acetaminophen or ibuprofen for fever relief—antibiotics should never be prescribed unless pneumonia is confirmed. 1, 2
Initial Assessment: Rule Out Serious Illness First
Before treating symptomatically, you must exclude pneumonia by checking for these red flags 1:
- Fever ≥38°C with tachycardia (>100 bpm) AND tachypnea (>24 breaths/min) 1
- New focal chest examination findings (crackles, diminished breath sounds, egophony) 1
- Dyspnea or pleural chest pain 1
If these features are present, obtain chest radiography and consider C-reactive protein (CRP >30 mg/L strengthens pneumonia diagnosis) 1. If pneumonia is confirmed or strongly suspected, use empiric antibiotics per local guidelines 1.
First-Line Symptomatic Treatment
For Cough
The American College of Chest Physicians strongly recommends first-generation antihistamine/decongestant combinations as first-line therapy 1:
- Brompheniramine with sustained-release pseudoephedrine 1
- These provide substantial benefit for postnasal drainage, throat clearing, and cough 2
Alternative: Naproxen 500 mg twice daily has specific evidence for reducing cough associated with the common cold 1, 2
For distressing cough only: Short-term codeine linctus (15-30 mg every 4 hours, maximum 4 doses/24 hours) or morphine sulfate oral solution (2.5-5 mg every 4 hours) may be considered 1. Simple honey (one teaspoon) is also reasonable for adults 1.
For Fever
Acetaminophen is preferred over NSAIDs for fever management 1:
- Standard dose: 1000 mg every 6 hours as needed 3, 4
- Use only while fever and associated symptoms are present 1
- Do not use antipyretics solely to reduce body temperature—treat for symptom relief 1
Ibuprofen is an acceptable alternative for fever, headache, malaise, and myalgia 1, 2, though paracetamol is preferred until more evidence emerges 1.
Critical Medications to AVOID
Never prescribe newer-generation nonsedating antihistamines (loratadine, cetirizine, fexofenadine)—they are completely ineffective for common cold symptoms 1, 2
Never prescribe antibiotics for uncomplicated acute cough, common cold, or acute bronchitis without confirmed pneumonia 1, 2. This is a consensus-based statement across all major guidelines. Antibiotics are prescribed inappropriately in 65-80% of acute bronchitis cases despite providing zero benefit 1.
Important Contraindications and Cautions
First-generation antihistamine/decongestants should be avoided in patients with 1:
- Glaucoma
- Benign prostatic hypertrophy
- Uncontrolled hypertension 2
- Renal failure
- Gastrointestinal bleeding risk
- Congestive heart failure
Decongestants may elevate blood pressure and blood glucose in susceptible patients 2.
When to Reassess for Bacterial Infection
Monitor for these warning signs that suggest bacterial complications 1, 2:
- Biphasic course: Initial improvement followed by worsening cough after 7 days 1
- Fever persisting beyond 48 hours of symptomatic treatment 2
- Development of focal chest signs, dyspnea, or hypoxemia 2
- Symptoms suggesting bacterial sinusitis (not diagnosed in first week of illness) 1, 2
Special Consideration: Suspected Influenza
If influenza is suspected, initiate antiviral treatment within 48 hours of symptom onset per CDC guidance—this may decrease antibiotic use, hospitalization, and improve outcomes 1
Natural History: Set Expectations
Approximately 25% of patients will still have cough, postnasal drainage, and throat clearing at day 14 even without treatment 1. This is the natural course of viral upper respiratory infections and does not indicate treatment failure or need for antibiotics 1.