What is the first line treatment for upper respiratory infections?

First-Line Treatment for Upper Respiratory Infections

Most upper respiratory tract infections (URTIs) are viral in origin and do not require antibiotics as first-line treatment; symptomatic management is recommended. 1, 2

Distinguishing Between URTIs and Treatment Approach

Viral URTIs (Most Common)

• First-line treatment: Symptomatic management with over-the-counter medications
  • Acetaminophen, ibuprofen, or naproxen for pain/fever
  • Antihistamines and/or decongestants for congestion and runny nose 3
• Antibiotics are NOT recommended for:
  • Common cold
  • Influenza
  • COVID-19
  • Laryngitis 2

When to Consider Antibiotics

Antibiotics should only be considered when there is strong evidence of bacterial infection:

1. Acute Rhinosinusitis: Consider antibiotics only if:

   • Symptoms last >10 days without improvement
   • Temperature >39°C (102.2°F)
   • Symptoms worsen after initial improvement 1

2. Acute Pharyngitis:

   • Only prescribe antibiotics if test or culture is positive for group A beta-hemolytic streptococcal pharyngitis 2

3. Persistent URTIs:

   • Consider antibiotics if fever (>38°C) persists for more than 3 days 4

Antibiotic Selection When Indicated

When antibiotics are truly necessary:

1. First-line antibiotic: Amoxicillin

   • For adults: 1.5-4g/day (typically 500mg three times daily or 875mg twice daily) 5
   • For children <30kg with pneumonia: 80-100 mg/kg/day in three daily doses 4, 5

2. For penicillin allergy:

   • Macrolides (though resistance is increasing)
   • Doxycycline (100mg twice daily for 5-7 days in adults) 5

3. For treatment failure or high-risk patients:

   • Amoxicillin-clavulanate (broader coverage against β-lactamase-producing organisms) 5

Duration of Treatment

• Adults: 5-7 days is generally as effective as longer courses with fewer adverse events 5
• Children: 10-14 days may be recommended 5
• Treatment should continue for 48-72 hours beyond symptom resolution 6

Important Clinical Considerations

• Monitor for improvement: Clinical improvement should be evident within 48-72 hours of starting appropriate therapy 5
• Reassessment: If symptoms worsen or fail to improve after 72 hours, consider alternative diagnosis or therapy 5
• Antibiotic resistance: Be aware of local resistance patterns before prescribing 5
• Bacterial vs. viral differentiation: Presence of ENT signs (rhinorrhea, obstruction of upper airways) suggests viral infection 4

Common Pitfalls to Avoid

1. Overprescribing antibiotics: URTIs are the most common reason for inappropriate antibiotic prescriptions in adults 1, 2
2. Failing to distinguish viral from bacterial etiology: Most URTIs are viral and self-limiting within 7-10 days 7
3. Not considering local resistance patterns: Increasing resistance to macrolides (>40% for S. pneumoniae) should influence antibiotic selection 5
4. Inadequate duration of treatment: Continue treatment for 48-72 hours after symptom resolution 6

Remember that inappropriate antibiotic use contributes to antibiotic resistance, adverse events, and unnecessary healthcare costs 2.