What is the recommended treatment for Upper Respiratory Tract Infections (URTI)?

Treatment of Upper Respiratory Tract Infections (URTI)

Upper respiratory tract infections should be managed primarily with symptomatic treatment, as antibiotics are not recommended for most URTIs due to their predominantly viral etiology. 1

Diagnostic Considerations

• URTIs are infections occurring above the vocal cords with normal pulmonary auscultation, distinguishing them from lower respiratory tract infections (LRTIs) 2
• Most URTIs are viral in origin and self-limiting, requiring only symptomatic management 3
• Common URTIs include the common cold, rhinosinusitis, pharyngitis, and acute otitis media 3

First-Line Treatment Approach

• Symptomatic treatment with analgesics for pain and antipyretics for fever is recommended for most uncomplicated URTIs 1
• Antibiotics should NOT be used to treat URTIs as they will not prevent progression to lower respiratory tract infections (Level A1 recommendation) 2, 1
• Over-the-counter medications for symptom management are appropriate, though caution is advised for children under 6 years 3

Specific Management Based on URTI Type

Common Cold

• Purely symptomatic management is indicated 3
• Antibiotics are rarely appropriate (used in only 1.9% of cases in observational studies) 4

Acute Rhinosinusitis

• Antibiotics should be reserved only for patients with:
  • Persistent symptoms for more than 10 days 1, 3
  • Severe symptoms including high fever with purulent nasal discharge or facial pain for at least 3 consecutive days 1
  • Worsening symptoms following initial improvement of a typical viral illness (double sickening) 1

Pharyngitis/Tonsillitis

• Antibiotics should only be prescribed if testing confirms streptococcal pharyngitis 3
• When bacterial etiology is confirmed, penicillin remains the drug of choice for tonsillopharyngitis 5
• Options include:
  • Benzathine penicillin as single-dose parenteral administration
  • Oral penicillin twice daily for 10 days 5

When Antibiotics Are Indicated

• For bacterial URTIs requiring antibiotics, amoxicillin is the FDA-approved first-line treatment 6
• Dosing for adults: 750 to 1750 mg/day in divided doses every 8 to 12 hours 6
• Dosing for pediatric patients over 3 months: 20 to 45 mg/kg/day in divided doses every 8 to 12 hours 6
• For neonates and infants under 3 months: maximum 30 mg/kg/day divided every 12 hours 6

Special Considerations

• Higher antibiotic doses may be needed in areas with high prevalence of resistant pneumococci 2
• Early intervention in URTIs may reduce symptom severity and viral transmission 7
• Mucoadhesive gel nasal sprays have shown promise for early intervention by creating a barrier against viral particles 7

Cautions and Pitfalls

• Despite being primarily viral, URTIs are among the most common reasons for inappropriate antibiotic prescriptions 3
• Antibiotic resistance is increasing in common URTI pathogens, particularly Streptococcus pneumoniae 5
• Potential adverse effects of antibiotics include:
  • Anaphylactic reactions (can be serious and occasionally fatal) 6
  • Severe cutaneous adverse reactions 6
  • Clostridioides difficile-associated diarrhea 6
  • Common side effects: diarrhea, rash, vomiting, and nausea 6

Alternative Approaches

• Complementary medicine approaches have been documented with low rates of subsequent antibiotic use (0.7%) and comparable costs to conventional treatment 4
• Homeopathic substances, including elderberry, are NOT recommended for prevention or treatment of URTIs (Level C4 recommendation) 1
• Inhaled antibiotics have been investigated for chronic rhinosinusitis in adults, but evidence remains insufficient and conflicting 8