What is the management approach for Upper Respiratory Infections (URIs)?

Management of Upper Respiratory Infections (URIs)

Most URIs are viral in nature and should be managed with symptomatic treatment only, avoiding unnecessary antibiotic use. 1

Diagnosis and Classification

Differentiating Viral from Bacterial Infections

• Viral URIs typically:

  • Last 5-7 days
  • Have early fever that resolves
  • Show improvement after 3-6 days 2
  • Present with cough, congestion, sore throat 1

• Bacterial sinusitis should be suspected when symptoms are:

  • Persistent: Nasal discharge or daytime cough not improving by 10 days
  • Worsening: New onset of fever, daytime cough, or nasal discharge after initial improvement
  • Severe: Persistent fever ≥39°C and purulent nasal discharge for at least 3 days 1

• Important: Purulent nasal discharge alone is NOT diagnostic of bacterial infection, as discharge often changes from clear to purulent and back to clear during uncomplicated viral URIs 2

Treatment Approach

1. Viral URIs (Common Cold, Nonspecific URI, Acute Cough Illness, Acute Bronchitis)

Management should focus on symptomatic relief. Antibiotics should NOT be prescribed for these conditions. 1

• Symptom management options:
  • Nasal saline irrigation
  • Acetaminophen or ibuprofen for pain/fever
  • First-generation antihistamine with decongestant (e.g., brompheniramine with pseudoephedrine) for cough and other symptoms 2
  • NSAIDs like naproxen for cough, headache, malaise, and myalgia 2
  • Topical decongestants for short-term relief (≤3-5 days to avoid rhinitis medicamentosa) 2
  • Antitussives for severe cough causing chest wall pain (limited efficacy) 2

2. Bacterial Infections

Acute Bacterial Sinusitis

When strict diagnostic criteria are met (persistent, worsening, or severe symptoms):

• Amoxicillin remains the drug of choice 3
• Higher dose (90 mg/kg/day) recommended for areas with high-level penicillin resistance 4
• Alternative antibiotics for specific indications include amoxicillin-clavulanate, certain cephalosporins, macrolides/azalides, and respiratory fluoroquinolones 4

Acute Pharyngitis (Group A Streptococcal)

• Only test if at least 2 of the following are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, absence of cough 2
• Penicillin remains the drug of choice 4
• Options include:
  • Single-dose parenteral benzathine penicillin
  • Oral penicillin twice daily for 10 days 4

Special Considerations

Children

• GAS pharyngitis should not be diagnosed in children younger than 3 years (rare in this age group) 1
• For AOM in children, observation can be considered for selected children, particularly those older than 2 years with nonsevere symptoms and unilateral disease 1
• In children with URI before age 6 undergoing anesthesia, inhaled salbutamol before general anesthesia is probably recommended 1

Prevention Strategies

• Hand hygiene is the most effective way to prevent transmission 2
• Mask use and social distancing recommended during outbreaks 2
• Annual influenza vaccination strongly recommended for all persons aged ≥65 years 2
• RSV vaccination recommended for adults aged ≥60 years and people aged ≥50 years with risk factors 2

Follow-up Recommendations

• Return for evaluation within 72 hours if symptoms worsen or fail to improve 2
• Elderly patients should be monitored closely for progression to lower respiratory tract infection 2
• Return for medical evaluation if fever >38°C persists for more than 48 hours, or if breathing difficulty or worsening symptoms occur 2

Common Pitfalls to Avoid

1. Overuse of antibiotics: Most URIs are viral and antibiotics are ineffective against viral illnesses 1, 2
2. Misdiagnosis of bacterial sinusitis: Imaging should not be performed routinely as many children with viral URI will have radiographic abnormalities 1
3. Relying solely on purulent discharge: This is not a reliable indicator of bacterial infection 2
4. Inadequate dosing: When antibiotics are indicated, ensure appropriate dosing (e.g., higher-dose amoxicillin for suspected resistant pneumococci) 4
5. Prolonged use of topical decongestants: Should not exceed 3-5 days due to risk of rhinitis medicamentosa 2

By following these evidence-based guidelines, clinicians can effectively manage URIs while minimizing unnecessary antibiotic use and its associated risks, including antibiotic resistance and adverse effects.