What is the treatment for acute upper respiratory infection?

Treatment for Acute Upper Respiratory Tract Infections

Most acute upper respiratory tract infections (URTIs) are viral in nature and should be managed with supportive care rather than antibiotics, as antibiotics are unnecessary in most cases and contribute to antibiotic resistance.

Classification and Diagnosis

• URTIs include infections occurring above the vocal cords, with normal pulmonary auscultation, including conditions like acute rhinosinusitis and acute otitis media 1
• Clinical assessment is essential to distinguish between viral and bacterial etiologies, as this determines appropriate treatment 1

Treatment Approach Based on Specific Conditions

Common Cold (Viral URI)

• Antibiotics should not be prescribed for the common cold as it is almost always viral in origin 2
• Recommended treatments include:
  • Over-the-counter analgesics for pain relief and fever reduction (acetaminophen, ibuprofen, or naproxen) 3
  • Nasal saline irrigation which may provide symptomatic relief 4
  • Decongestants and/or antihistamines for congestion and rhinorrhea in adults 5
  • For children over 1 year: honey can help with cough symptoms 5

Acute Rhinosinusitis

• Most cases of acute rhinosinusitis are viral and self-limiting 6

• Bacterial sinusitis should be suspected when:

  • Symptoms persist for more than 10 days without clinical improvement 6
  • Symptoms are severe (fever >39°C, purulent nasal discharge, facial pain lasting >3 consecutive days) 6
  • Symptoms worsen after an initial period of improvement ("double sickening") 6

• For confirmed bacterial maxillary sinusitis, antibiotic options include:

  • First-line: Amoxicillin-clavulanate 6
  • Alternatives for penicillin allergy: Second-generation cephalosporins (cefuroxime-axetil), third-generation cephalosporins (cefpodoxime-proxetil), or pristinamycin 6, 7
  • Standard treatment duration is 7-10 days 6

• Fluoroquinolones (levofloxacin, moxifloxacin) should be reserved for:

  • Complicated cases (frontal, fronto-ethmoidal, or sphenoidal sinusitis) 6
  • Failure of first-line therapy 6

• Supportive treatments include:

  • Intranasal saline irrigation 6
  • Intranasal corticosteroids 6
  • Analgesics for pain 6
  • Antipyretics for fever 6

Special Considerations

Antibiotic Resistance Concerns

• More than 80% of ambulatory care visits for sinusitis result in antibiotic prescriptions, most of which are unnecessary 6
• Inappropriate antibiotic use contributes to antibiotic resistance and exposes patients to adverse effects 2
• The number needed to treat with antibiotics for one patient to be cured rapidly of rhinosinusitis is 18, while the number needed to harm from adverse effects is only 8 6

When to Refer to a Specialist

• Patients with signs of complicated sinusitis (meningeal syndrome, exophthalmos, palpebral edema, ocular mobility disorders, severe pain) require hospitalization and parenteral antibiotics 6, 7
• Referral to a specialist (otolaryngologist, infectious disease specialist, or allergist) is indicated for:
  • Patients who are seriously ill 6
  • Patients who deteriorate clinically despite antibiotic therapy 6
  • Patients with recurrent episodes 6

Treatment Algorithm

1. Assess symptoms and duration:

   • If symptoms are mild to moderate, bilateral, and of short duration (<10 days) → Likely viral → Supportive care only 6, 8
   • If symptoms are severe, unilateral, or prolonged (>10 days) → Consider bacterial infection 6

2. For suspected bacterial infection:

   • First-line: Amoxicillin-clavulanate 6
   • For penicillin allergy: Cefuroxime-axetil, cefpodoxime-proxetil, or pristinamycin 6
   • Treatment duration: 7-10 days (5 days may be sufficient for certain cephalosporins) 6

3. For all patients, regardless of antibiotic use:

   • Saline nasal irrigation 4
   • Analgesics/antipyretics as needed 6
   • Consider intranasal corticosteroids 6

4. Monitor for improvement:

   • If no improvement or worsening after 48-72 hours of appropriate treatment, reassess diagnosis and consider referral 6