What is the treatment for Upper Respiratory Infections (URIs)?

Treatment of Upper Respiratory Infections

Most upper respiratory infections (URIs) are viral and should be managed with supportive care only—antibiotics should NOT be prescribed for nonspecific URI, common cold, acute cough illness, or acute bronchitis. 1

Distinguishing Viral from Bacterial URIs

The critical first step is determining whether a bacterial infection is present, as this fundamentally changes management 1:

Viral URIs (No Antibiotics Indicated)

• Common cold, nonspecific URI, acute cough illness, and acute bronchitis are viral and account for millions of visits annually 1
• These conditions present with cough, congestion, and sore throat but do NOT meet criteria for bacterial infection 1
• Antibiotics provide no benefit and only expose patients to potential harm 1

Bacterial URIs (May Require Antibiotics)

Only three specific bacterial URIs warrant consideration for antibiotic therapy 2:

1. Acute Otitis Media (AOM):

• Requires middle ear effusion PLUS moderate/severe bulging of tympanic membrane, OR otorrhea not due to otitis externa, OR mild bulging with ear pain or erythema 1, 2

2. Acute Bacterial Sinusitis:

• Symptoms must be worsening (new/worsening fever, cough, or nasal discharge after initial improvement), severe (fever ≥39°C with purulent discharge for ≥3 days), OR persistent (nasal discharge or cough >10 days without improvement) 1
• Imaging should NOT be performed routinely 1

3. Group A Streptococcal Pharyngitis:

• Only test if ≥2 of the following: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, absence of cough 1, 2
• Do NOT treat empirically without confirmation by rapid antigen test or throat culture 1, 2

Treatment Approach

For Viral URIs (Supportive Care Only)

Symptomatic management:

• Adequate hydration and fever management with antipyretics 2
• First-generation antihistamines may suppress cough in URI through anticholinergic effects 1
• Inhaled ipratropium bromide has shown benefit for cough suppression in URI or chronic bronchitis 1
• Guaifenesin (expectorant) decreased subjective cough measures in URI 1
• Dextromethorphan temporarily relieves cough due to minor throat and bronchial irritation 3
• Chest physiotherapy is NOT beneficial and should not be performed 2

Follow-up:

• Review if deteriorating or not improving after 48 hours 2

For Bacterial URIs (Antibiotic Therapy)

Acute Otitis Media:

• First-line: Amoxicillin 90 mg/kg/day 2
• High-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) if antibiotics received in previous 4-6 weeks or moderate disease 2
• Observation strategy acceptable for children >2 years with nonsevere symptoms and unilateral disease when adequate follow-up ensured 1, 2
• At least half of AOM patients recover without antibiotics, but recovery is more likely and faster with treatment 1

Acute Bacterial Sinusitis:

• First-line: Amoxicillin or amoxicillin-clavulanate 2
• Evidence is mixed—two trials showed benefit with strict diagnostic criteria and severe symptoms, one showed no benefit 1
• Consider observation for persistent symptoms only 2

Group A Streptococcal Pharyngitis:

• First-line: Amoxicillin or penicillin 2
• Antibiotics reduce suppurative complications and symptom duration 1
• Once-daily amoxicillin dosing is acceptable 2

Critical Considerations: Weighing Benefits vs Harms

Antibiotic-associated harms are substantial 1:

• Antibiotics cause >150,000 unplanned medical visits annually for adverse events in children 1
• Adverse events range from mild (diarrhea 5% increase, rash) to severe (Stevens-Johnson syndrome) to life-threatening (anaphylaxis, sudden cardiac death) 1
• Amoxicillin-clavulanate causes higher rates of diarrhea and dermatitis than amoxicillin alone (44% vs 14% in one sinusitis trial) 1
• Early-life antibiotic exposure may contribute to inflammatory bowel disease, obesity, eczema, and asthma 1
• Inappropriate use drives antibiotic resistance at individual and community levels 2

When diagnosis is uncertain, harms of antibiotics outweigh benefits 1

Common Pitfalls to Avoid

• Do NOT prescribe azithromycin as first-line for any pediatric URI—it has inadequate coverage for common AOM and sinusitis pathogens 2
• Do NOT treat pharyngitis empirically without testing—colonization rates reach 15-20% in asymptomatic children 1
• Do NOT use antibiotics for viral bronchitis—antibiotics are prescribed >70% of the time for acute bronchitis despite being purely viral 1
• Do NOT routinely image for sinusitis—many children with viral URI have radiographic abnormalities 1