What medications to prescribe for an upper respiratory infection (URI)?

Management of Upper Respiratory Infections

Most upper respiratory tract infections (URIs) are viral in nature and should be managed with supportive care only, without antibiotics. 1, 2

Diagnosis: Viral vs. Bacterial URI

Viral URI (Most Common)

• Common cold, nonspecific URI, acute cough illness, and acute bronchitis are typically viral
• Characterized by:
  • Runny nose, congestion, cough, sore throat
  • Symptoms typically improve within 7-10 days
  • No severe or worsening symptoms

Bacterial URI (Less Common)

• Suspect bacterial infection only if:
  • Symptoms persist without improvement for >10 days
  • Severe symptoms (fever ≥39°C with purulent nasal discharge for ≥3 days)
  • Symptoms worsen after initial improvement ("double sickening") 1, 2

Treatment Approach

For Viral URIs (Most Cases)

1. Supportive care only - the mainstay of treatment:

   • Adequate hydration
   • Analgesics for pain (acetaminophen or ibuprofen)
   • Antipyretics for fever
   • Saline nasal irrigation
   • Decongestants (systemic or topical) for symptomatic relief
   • Mucolytics if needed
   • Intranasal corticosteroids for nasal symptoms
   • Antihistamines for allergic symptoms 1, 2

2. Avoid antibiotics - they provide no benefit for viral infections and increase risk of:

   • Adverse effects (diarrhea, rash, abdominal pain)
   • C. difficile colitis
   • Development of antibiotic resistance
   • Unnecessary costs 1

For Bacterial URIs (Only When Criteria Met)

1. Acute Bacterial Rhinosinusitis:

   • First-line: Amoxicillin (if low risk for resistant organisms) 1, 3
   • Alternative: Amoxicillin-clavulanate (if high risk for resistant organisms) 1
   • High risk factors: Recent antibiotic use (<6 weeks), known high local prevalence of resistant organisms 1

2. Streptococcal Pharyngitis:

   • Only treat if confirmed by rapid antigen test or culture
   • First-line: Penicillin or amoxicillin 1, 3

3. Acute Otitis Media:

   • Treat based on age and severity criteria
   • First-line: Amoxicillin 1

Special Considerations

Observation Strategy

• "Wait and see" or delayed prescribing can be considered for:
  • Older patients with suspected bacterial sinusitis without severe symptoms
  • Selected cases of otitis media in children >2 years 1

Common Pitfalls to Avoid

1. Overdiagnosis of bacterial infections - most URIs are viral, even with purulent discharge
2. Inappropriate antibiotic use - more than 80% of sinusitis visits result in antibiotics, though most are unnecessary 1
3. Inappropriate imaging - radiographic imaging has no role in diagnosing bacterial sinusitis and would increase costs significantly 1
4. Using macrolides or oral third-generation cephalosporins - these have poor efficacy against common URI pathogens due to resistance 1

Follow-up Recommendations

• Return for care if:
  • Symptoms persist beyond 10 days
  • Symptoms worsen after initial improvement
  • Severe symptoms develop (high fever, difficulty breathing)
  • No improvement after 48 hours of treatment (if antibiotics were prescribed) 2

By following these evidence-based guidelines, providers can significantly reduce unnecessary antibiotic use while ensuring appropriate care for patients with URIs.