Most Likely Diagnosis and Management
This is a viral upper respiratory tract infection (common cold), and antibiotics are not indicated. 1, 2
Most Likely Diagnosis
The common cold is the single most common cause of acute cough with fever and upper respiratory symptoms. 1 The clinical presentation of 3 days of fever with cough and cold symptoms fits the classic viral URI syndrome, which typically includes nasal congestion, nasal discharge, postnasal drip, throat clearing, sneezing, and cough. 1
Key Diagnostic Features Supporting Viral Etiology
Symptom duration of only 3 days is too short to suggest bacterial complications. 1 Bacterial sinusitis should not be diagnosed during the first week of symptoms, as sinus imaging abnormalities seen during this period are typically due to the viral infection itself, not bacterial superinfection. 1
The vast majority (>90%) of acute upper respiratory infections are viral. 3, 2 At least 200 different viruses can cause the common cold syndrome, including rhinoviruses, coronaviruses, parainfluenza viruses, respiratory syncytial virus, adenoviruses, and enteroviruses. 1
Adults in the United States experience 2-4 colds per year. 1 This is an extremely common, self-limited condition that does not require antibiotics.
Recommended Management
What TO Do
Provide supportive care and symptomatic relief only. 1, 4, 2
First-generation antihistamine/decongestant combinations (e.g., brompheniramine with sustained-release pseudoephedrine) can reduce cough, postnasal drip, and throat clearing. 1 These have fair evidence supporting their use with substantial benefit. 1
Naproxen can be administered to help decrease cough in the setting of a common cold. 1
Over-the-counter preparations such as guaifenesin (200-400 mg every 4 hours, up to 6 times daily) are appropriate for symptomatic management. 4
Recommend adequate rest, adequate hydration, warm facial packs, steamy showers, and sleeping with the head of bed elevated. 4
What NOT To Do
Antibiotics should NOT be prescribed for the common cold, nonspecific URI, acute cough illness, or acute bronchitis. 1, 4, 2 This is one of the most critical management principles:
Antibiotics are explicitly contraindicated because the cause is not bacterial infection. 4 They provide no clinical benefit, contribute to antimicrobial resistance, and cause adverse effects including diarrhea, dermatitis, and C. difficile colitis. 1
Newer-generation nonsedating antihistamines are ineffective for reducing cough and should not be used. 1
Purulent or colored nasal discharge does NOT indicate bacterial infection and does not justify antibiotic treatment. 5, 2
Expected Timeline and Follow-Up
Acute viral URI symptoms generally respond to treatment within 10-14 days. 4 However, approximately 25% of patients may continue to have symptoms of cough, postnasal drip, and throat clearing at day 14. 1
When to Reassess
Instruct the patient to return immediately if any of the following develop: 4
- Fever develops or persists beyond 3-4 days total
- Hemoptysis occurs
- Symptoms worsen rather than gradually improve
- Symptoms have not improved within 3-5 days of treatment
If cough persists beyond 3 weeks, consider postinfectious cough or other diagnoses such as upper airway cough syndrome, asthma, or gastroesophageal reflux disease. 1, 4
Critical Differential Diagnoses to Exclude
Acute Bacterial Sinusitis
Do not diagnose bacterial sinusitis during the first week of symptoms. 1 Bacterial sinusitis requires one of three patterns: 1
- Persistent symptoms (nasal discharge or daytime cough) not improving by 10 days
- Worsening symptoms (new or worsening fever, cough, or nasal discharge after initial improvement)
- Severe symptoms (persistent fever ≥39°C and purulent nasal discharge for at least 3 consecutive days)
Pneumonia
Obtain a chest radiograph if any of the following are present: 1
- New focal chest signs (crackles, diminished breath sounds, dull percussion)
- Dyspnea or tachypnea
- Heart rate >100 bpm
- Fever persisting >4 days
The presence of focal auscultatory abnormalities raises the probability of pneumonia from 5-10% to approximately 39%. 1
Group A Streptococcal Pharyngitis
Do not treat pharyngitis empirically without testing. 1 GAS pharyngitis should be suspected only when the following are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, and absence of cough. 1 Testing is required before prescribing antibiotics. 1
Common Pitfalls to Avoid
Do not prescribe antibiotics for viral URI "just in case" or due to patient expectation. 1, 2 When asked, 44% of patients thought antibiotics were important for recovery from "acute bronchitis," but only 11% thought they were needed for "chest colds"—the descriptive term used matters. 1
Do not assume colored sputum indicates bacterial infection. 4, 5 Green or colored sputum is common in viral infections and does not predict bacterial etiology.
Do not fail to recognize when symptoms persist beyond the expected viral course (>3 weeks), requiring systematic evaluation for other causes. 4