What is the recommended treatment for upper respiratory infections?

Treatment of Upper Respiratory Tract Infections

Most upper respiratory tract infections (URTIs) are viral in origin and do not require antibiotic therapy; treatment should focus on symptomatic management unless specific bacterial etiologies are confirmed. 1, 2

Classification and Diagnosis

URTIs include infections that occur above the vocal cords, with normal pulmonary auscultation 3:

• Common cold (viral rhinitis)
• Acute rhinosinusitis
• Pharyngitis
• Acute otitis media

An initial clinical assessment is essential to distinguish between:

• Upper respiratory tract infections (above vocal cords)
• Lower respiratory tract infections (with cough and/or febrile polypnea) 3

Treatment Recommendations by Condition

Common Cold

• Antibiotics are not indicated as colds are almost exclusively viral 1, 2
• Symptomatic treatment with over-the-counter medications is recommended for adults 1
• FDA advises against OTC cold medications in children younger than 6 years 1

Acute Rhinosinusitis

• Most cases are viral and do not require antibiotics 1, 2

• Bacterial sinusitis should be suspected if:

  • Symptoms last longer than 10 days
  • Temperature exceeds 39°C (102.2°F)
  • Symptoms worsen after initial improvement 1

• For confirmed bacterial maxillary sinusitis, first-line antibiotics include:

  • Amoxicillin-clavulanate
  • Second-generation oral cephalosporins (cefuroxime-axetil)
  • Third-generation oral cephalosporins (cefpodoxime-proxetil, cefotiam-hexetil)
  • Pristinamycin (for beta-lactam allergies) 3

• Standard treatment duration is 7-10 days 3

Pharyngitis

• Most cases are viral and do not require antibiotics 1, 2
• Antibiotics should only be prescribed for confirmed group A beta-hemolytic streptococcal pharyngitis 2
• Testing (rapid strep test or culture) should be performed before prescribing antibiotics 2, 4

Acute Otitis Media

• Antibiotics are indicated for:

  • Children younger than 6 months
  • Children 6-23 months with bilateral AOM
  • Children older than 2 years with bilateral AOM and otorrhea
  • High-risk patients 1

• Recommended antibiotics include amoxicillin as first-line therapy for susceptible organisms 5

Special Considerations

Antibiotic Selection for URTIs

When antibiotics are truly indicated (confirmed bacterial infection):

• First-line for most URTIs: Amoxicillin for susceptible (β-lactamase–negative) isolates of Streptococcus species, Streptococcus pneumoniae, Staphylococcus spp., or Haemophilus influenzae 5

• For suspected resistant organisms: Amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil 3

• For beta-lactam allergies: Macrolides or pristinamycin 3

Duration of Treatment

• Treatment should continue for a minimum of 48 to 72 hours beyond symptom resolution 5
• Specific durations vary by condition:
  • Sinusitis: 7-10 days (5 days may be sufficient with certain cephalosporins) 3
  • Streptococcal pharyngitis: typically 10 days 3

Common Pitfalls to Avoid

• Overprescribing antibiotics: URTIs are the most common reason for inappropriate antibiotic prescriptions in adults, contributing to antibiotic resistance 1, 2

• Misdiagnosing viral conditions as bacterial: Bacterial etiology should be confirmed through appropriate testing (e.g., strep testing for pharyngitis) before prescribing antibiotics 2, 4

• Treating normal sinus inflammation: Distinguish between congestive rhinosinusitis (which accompanies viral rhinopharyngitis and doesn't require antibiotics) and true bacterial sinusitis 3

• Ignoring symptom duration: Bacterial sinusitis is more likely when symptoms persist beyond 10 days or worsen after initial improvement 1