What is the treatment approach for an upper respiratory infection (URI)?

Treatment Approach for Upper Respiratory Infections (URIs)

Most upper respiratory infections (URIs) are viral in origin and should be managed with supportive care only, without antibiotics, as antibiotics provide no benefit and can cause harm in viral infections. 1

Diagnosis and Classification

• URIs occur above the vocal cords and typically present with symptoms such as cough, fever, and respiratory distress with normal pulmonary auscultation 2
• Distinguishing viral from bacterial etiology is crucial for appropriate management 1
• ENT symptoms like rhinorrhea and nasal congestion suggest viral rather than bacterial etiology 3

First-Line Treatment for Uncomplicated URIs

• Supportive care is the mainstay of treatment for most patients with acute URI 1
• Analgesics may be offered for pain, and antipyretics for fever 1
• Additional symptomatic therapies that may provide relief include:
  • Systemic or topical decongestants 1
  • Saline nasal irrigation 1
  • Mucolytics 1
  • Intranasal corticosteroids 1
  • Antihistamines tailored to specific symptoms 1

When to Consider Antibiotics

Antibiotics should be reserved for specific situations:

• For acute rhinosinusitis, antibiotics should be considered only if:

  • Symptoms persist for more than 10 days without clinical improvement 1
  • Symptoms are severe (fever >39°C, purulent nasal discharge, or facial pain lasting for >3 consecutive days) 1
  • Symptoms worsen after an initial period of improvement ("double sickening") for more than 3 days 1
  • New-onset fever, headache, or increased nasal discharge occurs after a typical viral URI that was initially improving 1

• For bacterial pharyngitis, antibiotics should only be prescribed if test or culture results are positive for streptococcal infection 4

Antibiotic Selection When Indicated

• For acute bacterial rhinosinusitis:

  • Amoxicillin is the preferred agent according to some guidelines 1
  • Amoxicillin-clavulanate is preferred by IDSA guidelines due to concerns about antibiotic resistance 1
  • Doxycycline or a respiratory fluoroquinolone may be used as alternatives 1

• For upper respiratory tract infections caused by susceptible organisms:

  • Amoxicillin is FDA-approved for treatment of upper respiratory infections due to susceptible (β-lactamase–negative) isolates of Streptococcus species, S. pneumoniae, Staphylococcus species, or H. influenzae 5

Duration of Treatment

• For acute rhinosinusitis requiring antibiotics, treatment duration is typically 7-10 days 1
• Some cephalosporins (cefuroxime-axetil and cefpodoxime-proxetil) have shown efficacy with 5-day regimens 1

Monitoring and Follow-up

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

Important Caveats and Pitfalls

• Most patients diagnosed with acute rhinosinusitis have more adverse effects than benefits from antibiotics (number needed to harm: 8, number needed to treat: 18) 1
• Radiographic imaging has no role in ascertaining a bacterial cause of sinusitis and would increase costs at least 4-fold 1
• Patient satisfaction depends more on effective physician-patient communication than on antibiotic prescription 3
• Patients who are seriously ill, who deteriorate clinically despite antibiotic therapy, or who have recurrent episodes should be referred to a specialist 1
• Adjunctive therapy such as intranasal saline irrigation or intranasal corticosteroids can alleviate symptoms and potentially decrease antibiotic use 1