How should I manage a viral upper respiratory infection (head cold)?

Management of the Common Cold (Viral Upper Respiratory Infection)

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

What You Should Do

First-Line Symptomatic Treatment

Use combination antihistamine-decongestant-analgesic products as your primary therapy, as these provide superior symptom relief compared to single agents, with approximately 1 in 4 patients experiencing significant improvement. 2 Specifically, a first-generation antihistamine (like brompheniramine) combined with sustained-release pseudoephedrine effectively reduces nasal congestion, rhinorrhea, throat clearing, and cough. 1, 2

Pain and Fever Management

• Acetaminophen (paracetamol) 1000mg every 4-6 hours (maximum 4000mg/24 hours) is the preferred first-line agent due to superior safety—no gastrointestinal bleeding risk, no renal effects, and no cardiovascular toxicity. 3
• NSAIDs (ibuprofen 400-800mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing. 2

Additional Symptomatic Options

• Nasal saline irrigation provides modest relief by facilitating clearance of secretions. 3, 2
• Topical nasal decongestants (oxymetazoline) work for severe congestion but limit to 3-5 days maximum to avoid rebound rhinitis medicamentosa. 3, 2
• Dextromethorphan 60mg suppresses acute cough, though standard over-the-counter doses are likely subtherapeutic. 2
• Honey and lemon is a simple, inexpensive home remedy with patient-reported benefit. 2

Zinc Supplementation (Time-Sensitive)

Zinc lozenges (≥75mg/day as acetate or gluconate) reduce cold duration BUT only if started within 24 hours of symptom onset—no benefit if symptoms are already established beyond 24 hours. 1, 2 Weigh benefits against adverse effects including nausea and bad taste. 1

What You Should NOT Do

Never Prescribe Antibiotics

Antibiotics are not indicated for the common cold under any circumstances. 1, 3 They provide no benefit, do not shorten symptom duration, do not prevent complications (bacterial sinusitis, asthma exacerbation, or otitis media), and lead to significantly increased risk of adverse effects. 1 The number needed to harm from antibiotics (8) is lower than the number needed to treat for any benefit (18). 1

Avoid These Ineffective Therapies

• Non-sedating antihistamines (newer generation) are ineffective for common cold symptoms. 1, 2
• Intranasal corticosteroids provide no benefit for acute cold symptoms. 3, 2
• Vitamin C and echinacea have no proven benefit. 1, 3

Expected Timeline and When to Reassess

Normal Symptom Duration

• Sore throat peaks early and resolves by day 3-4. 2
• Fever and myalgia resolve within 5 days. 2
• Nasal congestion and cough persist longer, commonly continuing into the second and third week. 2
• Up to 25% of patients have symptoms for 14 days—this is normal and does not indicate bacterial infection. 2

Red Flags Requiring Reassessment

Reassess if any of the following occur: 1, 3

1. Persistent symptoms ≥10 days without any improvement (suggests possible bacterial rhinosinusitis)
2. High fever ≥39°C (102°F) with purulent nasal discharge or facial pain for ≥3-4 consecutive days
3. "Double sickening" pattern—worsening symptoms after initial improvement following a typical 5-6 day viral course

Critical Clinical Pitfalls to Avoid

Purulent Nasal Discharge Does NOT Mean Bacterial Infection

Do not prescribe antibiotics based on colored nasal discharge alone—this is a normal feature of viral colds reflecting neutrophil activity, not bacterial infection. 3, 2 This is one of the most common errors leading to inappropriate antibiotic prescribing.

Do Not Diagnose Bacterial Sinusitis in the First 10 Days

87% of patients show sinus abnormalities on CT during viral colds that resolve spontaneously without antibiotics. 2 Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 2

Patient Education Points

• Symptoms typically last 7-10 days, with up to 25% lasting 14 days. 2
• The illness is self-limiting and viral—antibiotics will not help. 3
• Hand hygiene is the most effective method to reduce transmission. 3
• Follow up only if symptoms worsen or exceed expected recovery time. 3

How to Maintain Patient Satisfaction Without Antibiotics

Patient satisfaction depends more on the quality of the encounter than receiving an antibiotic prescription. 1 Provide a symptomatic prescription plan (using the combination products above), explain why antibiotics are not needed, and give patient information sheets about appropriate management. 1 This approach has been shown to achieve an 85% decrease in antibiotic prescribing while increasing satisfaction ratings. 1