What is the management approach for upper respiratory tract infections in adults?

Management of Upper Respiratory Tract Infections in Adults

Most upper respiratory tract infections (URTIs) in adults are viral in nature and do not require antibiotic treatment. Symptomatic management should be the primary approach for most cases to avoid contributing to antibiotic resistance 1.

Diagnosis and Evaluation

Key Assessment Points

• Duration of symptoms
• Fever pattern
• Presence of purulent or colored sputum
• Specific symptoms (ear pain, facial pain, sore throat)
• Risk factors for complications

Red Flags Requiring Further Evaluation

• Systemically very unwell patients
• Features suggestive of serious illness or complications
• Pre-existing comorbidities
• Age >65 years with acute cough and risk factors:
  • Hospitalization in previous year
  • Diabetes
  • History of congestive heart failure
  • Current use of oral glucocorticoids 2

Treatment Algorithm

1. Viral URTIs (Most Common)

• First-line treatment: Symptomatic management only 1
  • Adequate hydration
  • Rest
  • Over-the-counter analgesics for pain and fever
  • Saline nasal irrigation
  • No antibiotics indicated

2. Bacterial URTIs

• When to suspect bacterial infection:

  • Symptoms persisting >10-14 days
  • Worsening symptoms after initial improvement
  • Severe symptoms from onset (high fever, purulent discharge)
  • Specific presentations (streptococcal pharyngitis, bacterial sinusitis)

• Diagnostic confirmation:

  • Rapid strep test or throat culture for suspected streptococcal pharyngitis
  • Clinical criteria for other bacterial URTIs

• Antibiotic selection:

  • First-line: Amoxicillin 1, 3

    • Dosage: 750-1750 mg/day in divided doses every 8-12 hours for 7-10 days 3

  • For suspected beta-lactamase producing organisms:

    • Amoxicillin-clavulanate 875/125 mg twice daily for 7 days 1

  • For penicillin allergy:

    • Macrolides (e.g., azithromycin 500 mg on day 1, then 250 mg daily for 4 days) 1
    • Cefuroxime-axetil 750 mg twice daily (if non-anaphylactic allergy) 1

3. Special Considerations for Specific URTIs

Acute Pharyngitis/Tonsillitis

• Confirm Group A beta-hemolytic streptococcus (GABHS) with rapid test or culture
• Treatment: Penicillin for 10 days or amoxicillin for 10 days 4
• Consider antibiotics with three or more Centor criteria (tonsillar exudate, tender anterior cervical lymphadenopathy, fever, absence of cough) 2

Acute Rhinosinusitis

• Most cases are viral and resolve spontaneously
• Consider antibiotics if symptoms persist >10 days or worsen after initial improvement
• First-line: Amoxicillin
• Alternative: Amoxicillin-clavulanate, especially for recurrent or chronic cases 4

Monitoring Response to Treatment

• Clinical response should be assessed within 3 days of starting antibiotics
• Symptoms should begin improving within 48-72 hours of effective treatment 1
• If no improvement after 72 hours:
  • Reevaluate diagnosis
  • Consider changing antibiotics
  • Consider referral to hospital 1

Prevention Strategies

• Influenza vaccination: Recommended yearly for persons at increased risk of complications 5:

  • Age >65 years
  • Institutionalization
  • Chronic cardiac diseases
  • Chronic pulmonary diseases
  • Diabetes mellitus
  • Chronic renal diseases
  • Pregnancy (second or third trimester during influenza season)

• Important note: Treatment of URTIs with antibiotics will not prevent lower respiratory tract infections (LRTIs) 5, 1

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral infections:

   • Most URTIs are viral and self-limiting
   • Antibiotics do not shorten duration or reduce symptoms in viral infections 1

2. Inappropriate use of fluoroquinolones:

   • Reserve for treatment failures or specific indications due to resistance concerns 1

3. Using macrolides as first-line therapy in areas with high pneumococcal resistance 1

4. Inadequate treatment duration:

   • Ensure complete course of antibiotics is taken, even if symptoms improve quickly 1

5. Treating upper respiratory infections with antibiotics to prevent lower respiratory infections:

   • This approach is not effective and contributes to antibiotic resistance 5

By following these evidence-based guidelines, clinicians can effectively manage URTIs while minimizing unnecessary antibiotic use and reducing the risk of antibiotic resistance.