What is the treatment for Upper Respiratory Infections (URIs)?

Treatment for Upper Respiratory Infections (URIs)

Most upper respiratory infections (URIs) are viral in nature and should be managed with supportive care only, without antibiotics, as antibiotics provide no benefit for viral infections and increase the risk of adverse effects. 1

Distinguishing Between Viral and Bacterial URIs

Common Cold (Viral URI)

• Self-limited viral illness characterized by:
  • Sneezing, rhinorrhea, sore throat
  • Cough, low-grade fever
  • Headache, malaise
• Treatment: Supportive care only, no antibiotics 1

Acute Bacterial Rhinosinusitis

Bacterial infection should be suspected only when:

• Symptoms persist without improvement for >10 days
• Severe symptoms including high fever (>39°C), purulent nasal discharge, or facial pain for ≥3 consecutive days
• "Double sickening" - worsening symptoms after initial improvement 1

Streptococcal Pharyngitis

• Primarily concerns patients >3 years old (rare in younger children) 1
• Testing (rapid antigen or culture) is required for diagnosis
• Antibiotics only if test is positive for Group A Streptococcus 1, 2

Treatment Algorithm

1. For Viral URIs (Common Cold)

• No antibiotics - they provide no benefit and increase risk of adverse effects 1
• Supportive care:
  • Analgesics for pain (acetaminophen, NSAIDs)
  • Antipyretics for fever
  • Symptomatic relief with:
    • Saline nasal irrigation
    • Topical or systemic decongestants
    • Mucolytics
    • Intranasal corticosteroids
    • Antihistamines (tailored to symptoms) 1

2. For Acute Bacterial Rhinosinusitis

• Reserve antibiotics only for:
  • Persistent symptoms >10 days without improvement
  • Severe symptoms (fever >39°C with purulent discharge/facial pain ≥3 days)
  • Worsening symptoms after initial improvement 1
• When antibiotics are indicated:
  • First-line: Amoxicillin (standard dosing) 1, 3
  • Alternative options:
    • Amoxicillin-clavulanate (if concern for resistant organisms)
    • Doxycycline or respiratory fluoroquinolone (for penicillin allergy) 1

3. For Streptococcal Pharyngitis

• Only treat with antibiotics if testing confirms Group A Streptococcus
• Treatment should continue for at least 10 days to prevent rheumatic fever 1, 3

Important Considerations

Risks of Inappropriate Antibiotic Use

• Adverse drug reactions (number needed to harm is 8) 1
• Development of antibiotic resistance
• Unnecessary medical costs 1
• A meta-analysis showed that for rhinosinusitis, the number needed to treat was 18 for one patient to be cured rapidly, while the number needed to harm was only 8 1

Special Populations

• Children under 3 years: Different treatment considerations apply, particularly for pharyngitis 1
• Immunocompromised patients: May require more aggressive management (not covered in these guidelines)

When to Refer to a Specialist

• Patients who are seriously ill
• Those who deteriorate despite antibiotic therapy
• Patients with recurrent episodes 1

Pitfalls to Avoid

1. Prescribing antibiotics for viral URIs - This is the most common error, occurring in up to 30% of common cold visits 1
2. Using radiographic imaging for diagnosis - Imaging cannot reliably distinguish between viral and bacterial causes of sinusitis and increases costs unnecessarily 1
3. Treating based on appearance of nasal discharge alone - Purulent discharge can occur with both viral and bacterial infections 1
4. Treating pharyngitis without testing - Even with typical symptoms, testing is required to confirm streptococcal pharyngitis 1

By following these evidence-based guidelines, clinicians can provide appropriate care for URIs while minimizing unnecessary antibiotic use and its associated risks.