What is the treatment approach for Upper Respiratory Tract Infections (URTI)?

Treatment Approach for Upper Respiratory Tract Infections (URTI)

Most URTIs are viral in origin and do not require antibiotics, with treatment focused on symptom management and supportive care. 1

Diagnostic Approach

Differentiating Viral from Bacterial Infections

• Most URTIs are viral and self-limiting, resolving within 7-10 days
• Consider bacterial infection when:
  • Symptoms persist >10 days without improvement
  • Severe symptoms with purulent nasal discharge and high fever (≥39°C)
  • Worsening symptoms after initial improvement ("double worsening") 1

Specific URTI Conditions

Acute Bacterial Sinusitis

• Diagnosis suggested by:
  • Symptoms lasting >10 days without improvement
  • Severe symptoms with purulent discharge and high fever
  • Worsening after initial improvement 2, 1
• Gold standard: positive bacterial culture from sinus puncture (rarely performed) 2

Streptococcal Pharyngitis

• Requires confirmation with appropriate testing before antibiotic treatment 1
• Group A β-hemolytic streptococci (GABHS) causes ~10% of adult cases and 15-30% of cases in children 2

Treatment Recommendations

Non-Antibiotic Management (First-Line for Most URTIs)

• Symptomatic relief:
  • Analgesics/antipyretics for pain and fever
  • Saline nasal irrigation
  • Adequate hydration
  • Rest 1, 3

Antibiotic Therapy (Only for Confirmed Bacterial Infections)

Acute Bacterial Sinusitis

• First-line: Amoxicillin (standard dose) 1
• For severe cases or high-risk of resistance: Amoxicillin-clavulanate 2, 1
• Alternatives for penicillin allergy:
  • Non-anaphylactic: Cefuroxime-axetil or cefpodoxime-proxetil
  • Anaphylactic: Pristinamycin 2, 1
• Duration: 7-10 days (some newer agents effective in 5 days) 2

Streptococcal Pharyngitis

• First-line: Penicillin (oral or intramuscular) 2
• Duration: 10 days to prevent complications like rheumatic fever 1
• Benefits: Reduces risk of suppurative complications and symptom duration 2

Dosing Guidelines

• Adults:
  • Amoxicillin: 500 mg every 12 hours (mild/moderate) or 875 mg every 12 hours (severe) 1, 4
• Children:
  • Weight-based dosing: 25-45 mg/kg/day divided every 12 hours 1, 4
• Treatment should continue for 48-72 hours beyond symptom resolution 4

Conditions NOT Requiring Antibiotics

• Common cold
• Viral rhinosinusitis
• Acute bronchitis (most cases)
• Laryngitis
• COVID-19
• Influenza 1

Special Considerations

Antibiotic Resistance

• Inappropriate antibiotic use contributes to resistance and adverse events
• Narrow-spectrum antibiotics should be preferred when appropriate 1

High-Risk Patients

• Consider immediate antibiotics for:
  • Systemically very unwell patients
  • Those with features of serious illness/complications
  • Patients with pre-existing comorbidities
  • Adults >65 years with acute cough and specific risk factors 3

Monitoring and Follow-up

• Monitor for clinical improvement within 48-72 hours of starting therapy
• Reassess if symptoms worsen or fail to improve after 72 hours 1

Prevention Strategies

• Treatment of URTIs with antibiotics will not prevent progression to lower respiratory tract infections 2
• Regular use of inhaled steroids or long-acting β-agonists is not recommended for URTI prevention 2
• Physiotherapy is not recommended as a preventive approach 2

Remember that careful selection of patients who truly need antibiotics is essential to avoid overuse and related side effects. Most URTIs will resolve with supportive care alone, and antibiotics should be reserved for cases with clear evidence of bacterial infection.