What is the appropriate treatment for an upper respiratory infection?

Treatment of Upper Respiratory Infections

Most upper respiratory infections (URIs) are viral in origin and do not require antibiotics; treatment should focus on symptomatic relief unless there is clear evidence of bacterial infection. 1, 2

Diagnostic Approach

Viral vs. Bacterial Differentiation

• URIs account for 20-40% of outpatient visits, with 87.5% involving the upper respiratory tract 3
• The vast majority (>85%) of URIs are caused by viruses and resolve spontaneously 3, 4
• Key bacterial pathogens when present:
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Streptococcus pyogenes (for pharyngitis) 5

Treatment Algorithm by Specific URI Type

1. Common Cold/Viral Nasopharyngitis

• Treatment: Symptomatic management only
  • Analgesics/antipyretics (acetaminophen, NSAIDs)
  • Adequate hydration
  • Rest
  • Nasal saline irrigation
• Antibiotics: Not indicated 1, 3
• Duration: Typically resolves in 7-10 days 6

2. Pharyngitis/Tonsillitis

• Diagnostic approach:

  • Rapid antigen test (RAT) for Group A Streptococcus (GAS)
  • Positive RAT confirms GAS etiology and justifies antibiotics (Grade A) 1
  • Negative RAT with low risk for acute rheumatic fever (ARF) does not require antibiotics 1

• Treatment for confirmed GAS pharyngitis:

  • First-line: Penicillin for 10-14 days 3, 4
  • Alternatives: Oral cephalosporins (cefaclor, cephalexin), amoxicillin, or macrolides 3

3. Acute Bacterial Sinusitis

• Diagnostic criteria: Purulent rhinorrhea (anterior/posterior, often unilateral) and pain upon pressure over infected sinus 1

• When to treat with antibiotics:

  • When diagnosis of acute purulent maxillary sinusitis is established (Grade B) 1
  • For symptoms persisting beyond 7-10 days or worsening after initial improvement 2

• Antibiotic treatment:

  • First-line: Amoxicillin 4
  • For treatment failure or high-risk patients: Amoxicillin-clavulanate 2, 7
    • Adults: 875 mg/125 mg twice daily 7
    • Children: 45 mg/kg/day divided twice daily 2, 7
  • Alternative for penicillin-allergic adults: Doxycycline or respiratory fluoroquinolone (last resort) 2
  • Duration: 5-7 days for uncomplicated cases 2

4. Acute Otitis Media

• When to treat with antibiotics:

  • All children <2 years
  • Children >2 years with bilateral AOM, otorrhea, comorbidities, or severe illness 4

• Antibiotic treatment:

  • First-line: Amoxicillin 4
  • For treatment failure: Amoxicillin-clavulanate 4
  • Duration: 10 days typically recommended 7

Special Considerations

Risk Factors for Resistant Organisms

• Recent antibiotic use (within 4-6 weeks)
• Age <2 or >65 years
• Daycare attendance
• Comorbidities
• Immunocompromised status 2

Treatment Response Assessment

• Clinical improvement should be expected within 48-72 hours of starting antibiotics
• If no improvement or worsening after 72 hours, consider:
  • Alternative antibiotic therapy
  • Reevaluation of diagnosis 2

Antibiotic Stewardship

• Antibiotics should not be used for common cold, viral rhinosinusitis, or acute bronchitis 2
• Complete the full antibiotic course when prescribed
• Emphasize hand hygiene and infection control measures to reduce transmission 2

Pitfalls to Avoid

1. Prescribing antibiotics for viral URIs, which exposes patients to potential harm without benefit
2. Failing to identify high-risk patients who may need broader antibiotic coverage
3. Not reassessing treatment efficacy after 48-72 hours
4. Using fluoroquinolones as first-line therapy due to safety concerns 2
5. Substituting two 250 mg/125 mg amoxicillin-clavulanate tablets for one 500 mg/125 mg tablet (not equivalent) 7

Remember that most URIs are self-limiting viral infections that resolve within 7-10 days with symptomatic treatment alone 6. Reserve antibiotics for cases with clear evidence of bacterial infection to minimize antibiotic resistance.