What is the first-line treatment for upper respiratory infections (URIs)?

First-Line Treatment for Upper Respiratory Infections

Most upper respiratory infections are viral and should be managed with supportive care alone—antibiotics are not indicated and cause more harm than benefit. 1

Initial Assessment: Viral vs. Bacterial

The vast majority of URIs are viral and self-limited, resolving within 7-10 days without antibiotics. 2, 3 The key clinical task is identifying the rare bacterial infections that warrant antibiotic therapy.

When Antibiotics Are NOT Indicated

• Common cold/viral rhinitis: Never requires antibiotics 4, 3
• Acute bronchitis: No antibiotics in otherwise healthy adults, even with fever present 5
• Laryngitis: No antibiotic indication 4, 3
• Influenza and COVID-19: Antiviral therapy only, not antibiotics 3

When to Consider Bacterial Infection

For acute rhinosinusitis, bacterial infection is likely only when: 1

• Symptoms persist >10 days without improvement, OR
• Severe symptoms (fever >39°C, purulent nasal discharge, facial pain) for ≥3 consecutive days, OR
• "Double sickening" (worsening after initial improvement)

For pharyngitis, only treat if: 3

• Positive rapid strep test or throat culture for Group A beta-hemolytic streptococcus

Recommended First-Line Treatment

For Viral URIs (Most Cases)

Supportive care is the cornerstone of management: 1

• Analgesics for pain
• Antipyretics for fever
• Saline nasal irrigation 1
• Intranasal corticosteroids for symptom relief 1
• Systemic or topical decongestants as needed 1

Important caveat: The FDA advises against over-the-counter cold medications in children younger than 6 years. 2

For Bacterial Rhinosinusitis (When Criteria Met)

Watchful waiting is preferred initially for uncomplicated cases, as most resolve without antibiotics even when bacterial. 1 The number needed to treat is 18 for one rapid cure, but the number needed to harm from antibiotic adverse effects is only 8. 1

If antibiotics are deemed necessary: 1, 6

• Preferred: Amoxicillin-clavulanate (per IDSA guidelines)
• Alternatives: Doxycycline or respiratory fluoroquinolone (levofloxacin, moxifloxacin) 1, 6
• Duration: 7-10 days (some cephalosporins effective in 5 days) 1

Note on antibiotic selection controversy: While IDSA recommends amoxicillin-clavulanate based on resistance concerns for H. influenzae and M. catarrhalis, other societies (American Academy of Family Physicians, American Academy of Allergy, Asthma & Immunology) recommend plain amoxicillin as first-line, and no direct evidence proves amoxicillin-clavulanate is superior. 1

For Streptococcal Pharyngitis

Only treat culture-positive or rapid-test-positive cases: 3

• First-line: Amoxicillin (per American Academy of Pediatrics) 6
• Alternative: First-generation cephalosporins 6
• Beta-lactam allergy: Macrolides 6

For Acute Otitis Media

Antibiotics are indicated in: 2

• Children <6 months (all cases)
• Children 6-23 months with bilateral AOM
• Children >2 years with bilateral AOM and otorrhea
• High-risk patients

First-line agent: Amoxicillin 80-100 mg/kg/day 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral URIs simply because patients expect them—this drives resistance and causes unnecessary adverse effects. 1, 3
• Do not use imaging to diagnose bacterial sinusitis; it has poor specificity (61%) and increases costs 4-fold without improving outcomes. 1
• Avoid fluoroquinolones as first-line therapy when narrower-spectrum antibiotics are appropriate—reserve these for specific indications to prevent resistance. 6, 5
• Do not use ciprofloxacin or older fluoroquinolones for respiratory infections—they have poor activity against S. pneumoniae. 6, 5
• Reassess within 48-72 hours if antibiotics are prescribed; do not change therapy before 72 hours unless clinical worsening occurs. 5

Special Populations

In children with maxillary sinusitis: 1

• Only occurs in children ≥3 years old
• Must distinguish from viral rhinosinusitis accompanying common cold
• First-line: Amoxicillin-clavulanate 80 mg/kg/day in three doses (max 3 g/day) OR cefpodoxime-proxetil 8 mg/kg/day 1
• Duration: 7-10 days 1

In patients with chronic obstructive bronchitis: 5

• Only treat if ≥2 of 3 Anthonisen criteria present (increased sputum volume, increased purulence, increased dyspnea)
• First-line: Amoxicillin for FEV1 >35% 5