What medications are recommended for treating Upper Respiratory Infections (URIs)?

Medication for Upper Respiratory Infections

Most upper respiratory infections (URIs) are viral and self-limited, requiring only supportive care with analgesics and antipyretics—antibiotics should be reserved exclusively for confirmed bacterial infections meeting specific diagnostic criteria. 1

Primary Treatment Approach: Supportive Care

The cornerstone of URI management is symptomatic treatment, not antibiotics. 1

Recommended Symptomatic Medications:

• Analgesics for pain relief (acetaminophen or ibuprofen) 1, 2
• Antipyretics for fever management 1, 2
• Intranasal saline irrigation to alleviate nasal symptoms and potentially decrease antibiotic use 1
• Systemic or topical decongestants for congestion (though evidence is limited) 1
• Intranasal corticosteroids for symptom relief 1

What NOT to Use:

• Over-the-counter combination cold medications are NOT recommended (except older antihistamine-decongestant combinations) 1
• Central cough suppressants (codeine, dextromethorphan) have limited efficacy for URI-related cough and are NOT recommended 1
• Zinc preparations are NOT recommended for acute cough due to common cold 1
• Albuterol is NOT recommended for cough not due to asthma 1

When Antibiotics Are Appropriate

Antibiotics should ONLY be prescribed when specific bacterial infections are confirmed or highly likely based on stringent clinical criteria. 1, 2

Acute Bacterial Rhinosinusitis (ABRS)

Clinical criteria indicating bacterial infection (requiring ALL of the following): 1

• Symptoms persisting >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 >3 days

Antibiotic selection for ABRS: 1

• First-line: Amoxicillin-clavulanate (preferred by IDSA guidelines due to coverage of β-lactamase-producing H. influenzae and M. catarrhalis)
• Alternatives: Doxycycline or respiratory fluoroquinolone for penicillin-allergic patients
• Important caveat: Some societies recommend amoxicillin alone as first-line due to lower adverse event rates, though no direct evidence proves amoxicillin-clavulanate superiority 1

Critical consideration: The number needed to treat is 18 for one patient to benefit, while the number needed to harm from antibiotic adverse effects is only 8—most patients have more harm than benefit from antibiotics 1

Streptococcal Pharyngitis

Antibiotics should ONLY be given after confirmed Group A Streptococcus by rapid antigen test or culture. 1, 2

• First-line: Penicillin or amoxicillin 2, 3
• Testing should only be performed if clinical criteria suggest bacterial infection (not viral pharyngitis) 1

Acute Otitis Media (Pediatric Context)

First-line: Amoxicillin (90 mg/kg/day) 2

• High-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) for children with recent antibiotic exposure or moderate disease 2
• Observation without immediate antibiotics may be appropriate for selected older children with nonsevere, unilateral disease 1, 2

Critical Pitfalls to Avoid

The Antibiotic Overuse Problem

• Over 80% of sinusitis visits result in antibiotic prescriptions, yet most are unnecessary 1
• Fewer than 2% of viral URIs are complicated by bacterial infection 1
• 62% of antibiotics globally are dispensed without prescription, with URTIs being the most common indication 1

Harms of Inappropriate Antibiotic Use

• Antibiotics cause >150,000 unplanned pediatric emergency visits annually for adverse events 1
• Adverse event rates (diarrhea, rash) occur in ~5% of patients, with amoxicillin-clavulanate having higher rates than amoxicillin alone 1
• Development of antibiotic resistance at individual and community levels 1
• Increased risk of C. difficile infection 1

Special Considerations

Watchful Waiting Strategy

The American Academy of Otolaryngology–Head and Neck Surgery recommends watchful waiting (without antibiotics) as initial management for uncomplicated ABRS, regardless of severity. 1 This approach:

• Reduces antibiotic exposure 1
• Requires close follow-up 1
• Does not result in worse clinical outcomes when properly implemented 1

Duration of Therapy

Shorter antibiotic courses (7 days vs. 10 days) achieve similar outcomes with fewer adverse effects in appropriate patients 1, 2

When to Refer

Refer to specialists (otolaryngology, infectious disease, allergy) if patients: 1

• Are seriously ill
• Deteriorate despite antibiotic therapy
• Have recurrent episodes