What is the treatment approach for upper respiratory infections?

Treatment Approach for Upper Respiratory Infections

Most upper respiratory tract infections (URIs) are viral in origin and do not require antibiotics; treatment should focus on symptom management while reserving antibiotics for specific bacterial infections with clear diagnostic criteria.

Determining the Cause of URI

Common Viral URIs (No Antibiotics Indicated)

• Common cold
• Viral rhinitis
• Viral pharyngitis
• Laryngitis
• Uncomplicated bronchitis
• Viral sinusitis (first 10 days)

Potential Bacterial URIs (Antibiotics May Be Indicated)

• Group A Streptococcal pharyngitis (confirmed by rapid antigen test)
• Acute otitis media (specific criteria)
• Bacterial sinusitis (specific criteria)
• Exacerbations of chronic bronchitis (specific criteria)

Symptom Management for Viral URIs

1. Analgesics/Antipyretics

   • Acetaminophen or NSAIDs (ibuprofen, naproxen) for pain and fever

2. Nasal Congestion

   • Saline nasal irrigation for symptomatic relief 1
   • Topical decongestants (e.g., oxymetazoline) for short-term use only (≤3 days) to avoid rhinitis medicamentosa 2
   • Oral decongestants (pseudoephedrine) with caution regarding cardiovascular side effects

3. Cough

   • Honey (for patients >1 year old)
   • Cough suppressants for symptomatic relief
   • Expectorants may help with productive cough

4. Supportive Care

   • Adequate hydration
   • Rest
   • Humidification

Specific Conditions Requiring Antibiotics

1. Acute Bacterial Sinusitis

Criteria for antibiotic therapy:

• Symptoms lasting >10 days without improvement
• Severe symptoms (high fever, purulent nasal discharge)
• Worsening symptoms after initial improvement 1

Recommended antibiotics:

• First-line: Amoxicillin (80 mg/kg/day in three doses, not exceeding 3g/day) for 7-10 days 2
• Alternative: Amoxicillin-clavulanate or cefpodoxime-proxetil 2

2. Group A Streptococcal Pharyngitis

Criteria for antibiotic therapy:

• Positive rapid antigen test or throat culture 1

Recommended antibiotics:

• Penicillin or amoxicillin for 10 days 1

3. Acute Otitis Media

Criteria for antibiotic therapy:

• Children <6 months of age
• Children 6-23 months with bilateral AOM
• Children >2 years with bilateral AOM and otorrhea
• Severe symptoms or high-risk patients 3

Recommended antibiotics:

• First-line: Amoxicillin 2, 4
• Alternative: Amoxicillin-clavulanate, cefuroxime-axetil 2

4. Exacerbations of Chronic Bronchitis

Criteria for antibiotic therapy (Anthonisen criteria):

• At least 2 of 3 criteria: increased dyspnea, increased sputum volume, increased sputum purulence 2, 1
• Persistent fever >38°C for more than 3 days 2

Recommended antibiotics:

• First-line (infrequent exacerbations): Amoxicillin, first-generation cephalosporins, macrolides, or doxycycline 2, 1
• Second-line (frequent exacerbations or treatment failure): Amoxicillin-clavulanate, second/third-generation cephalosporins, respiratory fluoroquinolones 2, 1

Special Considerations

Children Under 6 Years

• Avoid OTC cough and cold medications due to potential toxicity and limited efficacy 2
• Focus on supportive care and symptom management

Antibiotic Stewardship

• Explain to patients that most URIs are viral and self-limiting 1
• Educate about expected duration of symptoms (cough typically lasts 2-3 weeks regardless of treatment) 1
• Discuss risks of unnecessary antibiotic use, including resistance and side effects 1

When to Return/Seek Further Care

• Fever persisting >3-4 days
• Symptoms worsening after initial improvement
• Development of shortness of breath
• Symptoms persisting beyond 10-14 days without improvement 1

Treatment Duration

• Bacterial sinusitis: 7-10 days 2
• Streptococcal pharyngitis: 10 days 1
• Acute otitis media: 7-10 days 2
• Exacerbations of chronic bronchitis: 7-10 days 2

Remember that clinical effect of antibiotic treatment should be expected within 3 days, and fever should resolve within 2-3 days of antibiotic initiation 1. If improvement is not seen within this timeframe, reassessment is warranted.