What is the treatment approach for upper respiratory infections?

Treatment Approach for Upper Respiratory Infections

Most upper respiratory infections (URIs) are viral in nature and should be managed with symptomatic treatment rather than antibiotics. 1, 2

Determining the Cause of Upper Respiratory Infection

Viral vs. Bacterial Assessment

• Most URIs are caused by viruses and will resolve within 7-10 days with symptomatic treatment 2, 3
• Consider bacterial infection if:
  • Symptoms persist beyond 10 days
  • Fever >37.8°C with tachycardia >100 bpm and/or polypnea >25/min 4
  • Presence of focal signs on auscultation
  • Purulent sputum with at least two of the Anthonisen criteria (increased dyspnea, increased sputum purulence, increased sputum volume) 4, 1

Treatment Algorithm

1. Viral Upper Respiratory Infections (Most Common)

• Symptomatic treatment only - antibiotics should not be prescribed 1, 2
• Recommended symptomatic treatments:
  • Acetaminophen or NSAIDs for pain/fever
  • Adequate hydration and rest
  • Saline nasal irrigation
  • Honey for cough (in patients >1 year old) 1

2. Bacterial Upper Respiratory Infections

• For suspected bacterial infections affecting the upper respiratory tract:

  • First-line: Amoxicillin (1.5-4g/day divided in 2-3 doses for adults; 80-100 mg/kg/day in three daily doses for children <30kg) 1, 5
  • Duration: 7-10 days for most infections 1

• For suspected beta-lactamase producing pathogens:

  • First-line: Amoxicillin-clavulanate (same dosing as above for the amoxicillin component) 1
  • Alternatives for penicillin allergy: Macrolides or second/third generation cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) 4, 1

Specific URI Conditions

Acute Bronchitis in Otherwise Healthy Adults

• Antibiotics are generally not recommended as the clinical course is usually self-limiting within 10 days 4
• The onset of purulent sputum during acute bronchitis in healthy adults is not indicative of bacterial superinfection 4
• NSAIDs at anti-inflammatory doses or systemic corticosteroids are not justified 4

Community-Acquired Pneumonia (without risk factors or severe symptoms)

• Adults >40 years: Oral amoxicillin 3g/day 4
• Adults <40 years with suspected atypical bacteria: Oral macrolides 4
• Telithromycin represents an alternative to these treatments 4

Acute Sinusitis

• Immediate antibiotic therapy for severe purulent forms 4
• First-line options:
  • Amoxicillin-clavulanate
  • Second generation oral cephalosporins (cefuroxime-axetil)
  • Third generation oral cephalosporins (cefpodoxime-proxetil, cefotiam-hexetil)
  • Pristinamycin (in case of allergy to beta-lactams) 4
• Treatment duration: 7-10 days (5 days may be sufficient with certain cephalosporins) 4

Monitoring and Follow-up

• Assess therapeutic efficacy within 3 days of treatment initiation
• Symptoms should decrease within 48-72 hours with effective treatment
• If no improvement after 72 hours, reassess diagnosis and consider alternative antibiotics 1

Common Pitfalls to Avoid

1. Overprescribing antibiotics for viral URIs - most URIs are viral and do not require antibiotics 2, 6
2. Misinterpreting purulent sputum as bacterial infection - purulent sputum can occur in viral infections 4
3. Using fluoroquinolones as first-line treatment - these should be reserved for treatment failures or complicated infections 1
4. Inadequate duration of antibiotic therapy - premature discontinuation can lead to treatment failure and resistance
5. Failure to reassess non-responding patients - if symptoms worsen or fail to improve after 72 hours, the diagnosis should be reconsidered 1

By following this evidence-based approach, unnecessary antibiotic use can be reduced while ensuring appropriate treatment for bacterial URIs when indicated.