What is the appropriate treatment for an otherwise healthy adult with an acute viral upper‑respiratory infection (common cold) presenting with cough?

Treatment for Cold and Cough in Healthy Adults

For an otherwise healthy adult with acute viral upper respiratory infection and cough, the most effective treatment is a combination antihistamine-decongestant-analgesic product, which provides significant symptom relief in approximately 1 in 4 patients, while antibiotics should never be prescribed as they offer no benefit and contribute to antimicrobial resistance. 1, 2

Initial Assessment: Rule Out Serious Conditions First

Before treating as a simple cold, directly ask about and examine for these red flags that require different management:

• Hemoptysis (any amount) → requires chest radiograph and possible bronchoscopy 3, 1
• Fever >38°C persisting beyond 3 days or appearing after initial improvement 1
• Acute breathlessness → assess for asthma or anaphylaxis 3
• Suspected foreign body inhalation → mandatory bronchoscopy referral 3, 1
• Pneumonia signs: heart rate ≥100 beats/min, respiratory rate ≥24 breaths/min, oral temperature ≥38°C, or focal consolidation on chest exam (dullness, bronchial breathing, crackles) 3, 1

Critical pitfall: Purulent (colored) sputum does NOT indicate bacterial infection—it reflects normal viral inflammation and should not trigger antibiotic use 3, 2

First-Line Symptomatic Treatment

Most Effective: Combination Products

Use combination antihistamine-decongestant-analgesic preparations as they provide superior relief compared to single agents (odds ratio of treatment failure 0.47; number needed to treat = 5.6) 1, 2

Specifically effective combinations include:

• First-generation antihistamine (e.g., brompheniramine) + sustained-release pseudoephedrine + analgesic 3, 1
• These address multiple symptoms simultaneously: congestion, rhinorrhea, headache, and malaise 3, 1

Important caveat: First-generation antihistamines cause sedation, so warn patients about drowsiness and avoid driving/operating machinery 3

For Nasal Congestion

• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit 1, 4
• Topical nasal decongestants (e.g., oxymetazoline) are effective BUT limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1, 2, 4
• Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve congestion 1, 4

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 1, 2
• Acetaminophen/paracetamol (1000 mg every 4-6 hours, max 4000 mg/24 hours) may help nasal obstruction and rhinorrhea but does not improve other symptoms as effectively as NSAIDs 1, 2

For Cough

• Dextromethorphan 60 mg for maximum cough suppression (standard over-the-counter doses are likely subtherapeutic) 3, 4
• Menthol inhalation provides acute but short-lived cough suppression 3, 1
• Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit 3, 1
• Avoid codeine and other opiate antitussives—they have no greater efficacy than dextromethorphan but significantly more adverse effects 3, 1

Important note: Newer nonsedating antihistamines are ineffective for cold symptoms and should not be used 3, 1, 2

Evidence-Based Adjunctive Therapies

Zinc Lozenges (Time-Sensitive)

Zinc lozenges (≥75 mg/day as acetate or gluconate) significantly reduce cold duration BUT only if started within 24 hours of symptom onset 1, 2

• No benefit if symptoms already established beyond 24 hours 1
• Side effects include bad taste and nausea 1
• This is the only intervention proven to shorten illness duration 1, 5

Nasal Saline Irrigation

• Provides modest symptom relief by diluting secretions and facilitating elimination 1, 2
• Safe with no adverse effects 1

What Does NOT Work (Avoid These)

• Antibiotics: No benefit for uncomplicated common cold, contribute to antimicrobial resistance, and increase adverse effects 3, 1, 2, 6
• Intranasal corticosteroids: Ineffective for acute cold symptoms 1, 2
• Newer-generation nonsedating antihistamines: Ineffective 3, 1
• Echinacea, vitamin C (for treatment): No proven benefit 2, 4, 5

Expected Timeline and When to Reassess

Normal Course

• Symptoms typically last 7-10 days 1, 2
• Up to 25% of patients have symptoms for 14 days—this is normal and does not indicate bacterial infection 1, 2
• Cough may persist into the second and third week 1

When to Suspect Bacterial Complication

Only 0.5-2% of viral URIs develop bacterial complications 1

Reassess if patient has:

• "Double sickening" pattern (initial improvement followed by worsening) 3, 1, 2
• Symptoms persisting >10 days without any improvement 1, 2
• High fever ≥39°C with purulent nasal discharge or facial pain for ≥3-4 consecutive days 2

Even then, consider bacterial infection only if at least 3 of 5 criteria are present: discolored nasal discharge, severe local pain, fever >38°C, double sickening pattern, elevated inflammatory markers 1

Key Patient Education Points

• The illness is self-limiting and viral—antibiotics will not help 1, 2
• Colored nasal discharge is normal during a viral cold and does not mean bacterial infection 1, 2
• Symptoms resolve without antibiotics even when bacterial pathogens are present 2
• Hand hygiene is the most effective prevention method 2

Special Populations

• Pregnant women: Acetaminophen is first-line for pain and fever 1
• Contraindications to first-generation antihistamines/decongestants: Glaucoma, benign prostatic hypertrophy, uncontrolled hypertension, renal failure, gastrointestinal bleeding, congestive heart failure 3