What is the appropriate first‑line pharmacologic treatment for an adult with a common‑cold presentation (clear‑to‑colored nasal discharge, productive cough, post‑nasal drip) and when, if ever, should amoxicillin be prescribed?

First-Line Pharmacologic Treatment for Common Cold and When to Prescribe Amoxicillin

Do not prescribe antibiotics—including amoxicillin—for the common cold; symptomatic therapy with analgesics, decongestants, and saline nasal irrigation is the appropriate management strategy. 1

Understanding the Common Cold vs. Bacterial Sinusitis

The common cold is a benign, self-limited viral illness affecting approximately 37 million Americans annually, yet roughly 30% of ambulatory visits result in an inappropriate antibiotic prescription. 1 Approximately 98–99.5% of acute rhinosinusitis cases are viral and resolve spontaneously within 7–10 days without antibiotics. 1, 2

Key Clinical Features of Viral Common Cold

• Sneezing, clear-to-colored nasal discharge (color does not indicate bacterial infection), productive cough, post-nasal drip, sore throat, low-grade fever, headache, and malaise 1, 3
• Purulent (colored) nasal discharge reflects neutrophil activity in viral inflammation, not bacterial infection, and should not trigger antibiotic therapy 2, 3
• Symptoms typically last up to 2 weeks and improve without intervention 1, 3

First-Line Symptomatic Treatment

Analgesics and Antipyretics

• Acetaminophen or ibuprofen for pain relief and fever control 1, 3, 4
• Acetaminophen up to 4 g/24 hours is first-line due to superior safety profile (no GI bleeding, renal, or cardiovascular toxicity compared to NSAIDs) 3

Nasal Symptom Relief

• Saline nasal irrigation 2–3 times daily provides cleansing and modest symptom relief by facilitating clearance of nasal secretions 1, 3, 5
• Combination antihistamine-analgesic-decongestant products provide significant symptom relief in 1 out of 4 patients treated 1, 3
• Topical decongestants (e.g., oxymetazoline) may be used for severe congestion but limit to 3 days maximum to avoid rebound rhinitis medicamentosa 3, 5
• Oral decongestants (pseudoephedrine) modestly reduce severity and duration but avoid in patients with hypertension, cardiac disease, or glaucoma 5, 4

Other Symptomatic Options

• Inhaled ipratropium bromide for rhinorrhea 1
• Zinc lozenges (≥75 mg/day as acetate or gluconate) started within 24 hours of symptom onset may reduce duration, but weigh benefits against adverse effects (nausea, bad taste) 1, 3, 5
• Antitussives for cough suppression 1

Ineffective Therapies to Avoid

• Vitamin C and echinacea have no proven benefit 1, 3, 4
• Intranasal corticosteroids provide no benefit for common cold symptomatic relief 3
• Antihistamines alone have more adverse effects than benefits 1

When Antibiotics Are NOT Indicated

Antibiotics should not be prescribed for the common cold because: 1, 3

• They are not effective against viral infections
• They lead to significantly increased risk of adverse effects (diarrhea in 40–43% of patients receiving amoxicillin-clavulanate, severe diarrhea in 7–8%) 2
• They do not prevent complications such as bacterial sinusitis, asthma exacerbation, or otitis media 1, 3
• They contribute to antimicrobial resistance 1
• The number needed to treat (NNT) is 10–15 to achieve one additional cure even when bacterial infection is present, while adverse events are far more common 2

When to Consider Amoxicillin: Criteria for Acute Bacterial Rhinosinusitis

Amoxicillin (or preferably amoxicillin-clavulanate) should be reserved only when acute bacterial rhinosinusitis is confirmed by at least one of the following three patterns: 1, 2, 5

Pattern 1: Persistent Symptoms ≥10 Days

• Purulent nasal discharge plus nasal obstruction/congestion or facial pain/pressure/fullness lasting ≥10 days without improvement 1, 2, 6, 7
• This is the most common scenario warranting antibiotics 2

Pattern 2: Severe Symptoms ≥3–4 Consecutive Days

• High fever ≥39°C (102.2°F) together with purulent nasal discharge and facial pain for at least 3–4 consecutive days at illness onset 1, 2, 5
• Immediate antibiotic therapy is recommended without waiting for the 10-day threshold 2

Pattern 3: "Double Sickening"

• Initial improvement from a viral URI followed by new-onset fever, worsening nasal discharge, or markedly increased cough within 10 days 1, 2, 5
• This biphasic course strongly suggests bacterial superinfection 2

Antibiotic Selection When Bacterial Sinusitis is Confirmed

First-Line Regimen

• Amoxicillin-clavulanate 875 mg/125 mg twice daily for 5–10 days (or until symptom-free for 7 consecutive days) provides 90–92% predicted clinical efficacy against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2, 5, 8
• Amoxicillin-clavulanate is preferred over plain amoxicillin due to increasing prevalence of β-lactamase-producing organisms (30–40% of H. influenzae and 90–100% of M. catarrhalis) 1, 2, 6

High-Dose Regimen for Risk Factors

• High-dose amoxicillin-clavulanate (2 g/125 mg twice daily) for patients with recent antibiotic use (≤4–6 weeks), age >65 years, daycare exposure, moderate-to-severe symptoms, or comorbidities 2, 5

Alternatives for Penicillin Allergy

• Non-severe allergy: Second- or third-generation cephalosporins (cefuroxime, cefpodoxime, cefdinir) for 10 days; cross-reactivity is negligible 1, 2, 6
• Severe (anaphylactic) allergy: Respiratory fluoroquinolones (levofloxacin 500 mg once daily for 10–14 days or moxifloxacin 400 mg once daily for 10 days) with 90–92% predicted efficacy 1, 2, 8
• Doxycycline 100 mg once daily for 10 days is acceptable but inferior (77–81% efficacy, 20–25% failure rate) 2

Antibiotics to Avoid

• Azithromycin and macrolides are explicitly contraindicated due to 20–25% resistance rates 1, 2, 5
• Trimethoprim-sulfamethoxazole shows ~50% resistance in S. pneumoniae 2

Essential Adjunctive Therapies (Add to All Patients)

• Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily significantly reduce mucosal inflammation and accelerate symptom resolution; supported by strong evidence from multiple randomized controlled trials 1, 2, 5
• Saline nasal irrigation 2–3 times daily for symptomatic relief 1, 2, 5
• Analgesics (acetaminophen or ibuprofen) for pain and fever control 1, 2, 5

Monitoring and Reassessment

• Reassess at 3–5 days: If no improvement (persistent purulent drainage, unchanged facial pain, or worsening), switch to high-dose amoxicillin-clavulanate or respiratory fluoroquinolone 1, 2, 5
• Reassess at 7 days: If symptoms persist or worsen, reconfirm diagnosis, exclude complications (orbital cellulitis, meningitis), and consider imaging or ENT referral 1, 2
• Expected timeline: Most patients show noticeable improvement within 3–5 days, with complete resolution by 10–14 days 2, 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics for symptoms <10 days unless severe features (fever ≥39°C with purulent discharge for ≥3 consecutive days) are present 1, 2, 7
• Do not use purulent nasal discharge alone as an indication for antibiotics—it is a normal feature of viral colds 2, 3
• Do not obtain routine imaging (X-ray or CT) for uncomplicated cases; up to 87% of viral URIs show sinus abnormalities on imaging 2
• Ensure adequate treatment duration (≥5 days for adults, ≥10 days for children) to prevent relapse 2

Patient Education

• Advise patients that symptoms typically last up to 2 weeks and are self-limited 1, 3
• Instruct patients to follow up if symptoms worsen or exceed expected recovery time 1, 3
• Emphasize that hand hygiene is the most effective method to reduce transmission 1, 3
• Reassure patients that antibiotics are not needed and may have adverse effects 1, 3