What is the treatment approach for upper respiratory infections?

Treatment Approach for Upper Respiratory Infections

Most upper respiratory tract infections (URTIs) are viral in origin and should be managed with symptomatic treatment only, without antibiotics. 1, 2

Diagnosis and Classification

• URTIs occur above the vocal cords and typically present with symptoms such as cough, fever, and respiratory distress of varying intensity with normal pulmonary auscultation 3
• Common URTIs include the common cold, rhinosinusitis, pharyngitis, and acute otitis media 1
• It is essential to distinguish between viral and bacterial infections to avoid unnecessary antibiotic use 2

Treatment Algorithm by Specific URTI Type

Common Cold

• Antibiotics are not recommended as colds are almost exclusively viral 2
• Management focuses on symptomatic relief with over-the-counter medications 1
• Caution: FDA advises against using OTC cold medications in children younger than 6 years 1

Acute Rhinosinusitis

• Primarily viral in origin (>95% of cases) 4
• Antibiotics are only indicated if:
  • Symptoms persist longer than 10 days 1
  • Temperature exceeds 39°C (102.2°F) 1
  • Symptoms worsen after initial improvement (double worsening) 1
• When antibiotics are needed, amoxicillin is the drug of choice 4, 5

Pharyngitis

• Most cases (>80%) are viral in origin 4
• Antibiotics should only be prescribed for confirmed streptococcal pharyngitis (positive rapid antigen test or throat culture) 1, 4
• For streptococcal pharyngitis, penicillin V is the treatment of choice 4

Acute Otitis Media

• Antibiotics are indicated for:
  • Children younger than 6 months 1
  • Children 6-23 months with bilateral AOM 1
  • Children older than 2 years with bilateral AOM and otorrhea 1
  • High-risk patients 1
• Amoxicillin is the drug of choice in regions with low pneumococcal resistance 4, 5

Antibiotic Selection When Indicated

• First-line: Amoxicillin for susceptible (β-lactamase-negative) infections due to Streptococcus species, S. pneumoniae, Staphylococcus spp., or H. influenzae 5
• For penicillin allergy: Macrolides, pristinamycin, or doxycycline 3
• For treatment failures: Consider amoxicillin-clavulanate, which provides better coverage against β-lactamase producing H. influenzae and M. catarrhalis 4

Duration of Treatment

• Treatment should continue for a minimum of 48 to 72 hours beyond symptom resolution 5
• For specific infections like pneumonia, longer durations may be required (10 days for pneumococcal pneumonia, 14 days for atypical pneumonia) 3

Monitoring and Follow-up

• Clinical follow-up is essential, with reassessment during the following 2-3 days if symptoms persist or worsen 6
• Fever should resolve within 2-3 days of effective treatment 6
• Persistent fever (>38°C) for more than 3 days suggests bacterial infection requiring antibiotic therapy 6

Important Caveats and Pitfalls

• Overuse of antibiotics: URTIs account for the most common reason for antibiotic prescriptions in adults, despite most being viral 1, 2
• Antibiotic resistance: Inappropriate use contributes to resistance, adverse events, and unnecessary costs 2
• ENT symptoms: Rhinorrhea and nasal congestion suggest viral rather than bacterial etiology 6
• Patient expectations: Patient satisfaction depends more on effective physician-patient communication than on antibiotic prescription 6
• Red flags requiring immediate attention: Persistent fever >3 days, worsening shortness of breath, or severe respiratory distress may indicate bacterial infection or pneumonia requiring specific treatment 6