What is the first-line treatment for upper respiratory tract infection (URTI) in a relatively healthy person?

First-Line Treatment for Upper Respiratory Tract Infections in Healthy Adults

For most upper respiratory tract infections in healthy individuals, symptomatic treatment alone is the appropriate first-line approach, as the vast majority are viral and antibiotics cause more harm than benefit. 1, 2

Initial Management: Supportive Care

The cornerstone of URTI management is symptomatic relief without antibiotics 1:

• Analgesics (acetaminophen, NSAIDs) for pain relief 1
• Antipyretics for fever control 1
• Saline nasal irrigation for nasal congestion 1
• Intranasal corticosteroids for symptom relief 1
• Systemic or topical decongestants as needed 1

Most URTIs are viral and self-limiting, requiring only these supportive measures 3, 2. Antibiotics are inappropriate for common cold, influenza, COVID-19, and laryngitis 2.

When Antibiotics ARE Indicated

Acute Bacterial Rhinosinusitis

Antibiotics should only be prescribed when specific criteria are met 4:

Indications for antibiotic therapy:

• Symptoms lasting >10 days without improvement 3
• Severe symptoms with fever >39°C (102.2°F) 3
• Worsening symptoms after initial improvement ("double-sickening") 3
• Unilateral facial pain with purulent discharge 4

First-line antibiotics for confirmed bacterial sinusitis 4, 1:

• Amoxicillin-clavulanate (preferred agent) 1
• Cefuroxime-axetil (2nd generation cephalosporin) 4, 1
• Cefpodoxime-proxetil (3rd generation cephalosporin) 4, 1
• Pristinamycin (for beta-lactam allergies) 4, 5

Duration: 7-10 days (cefuroxime-axetil and cefpodoxime-proxetil effective in 5 days) 4, 5

Important caveat: First-line antibiotics are NOT indicated when nasal symptoms remain diffuse, bilateral, and of moderate intensity with serous discharge occurring in an epidemic context 4. Reassess after 48-72 hours of symptomatic treatment 4.

Streptococcal Pharyngitis

Antibiotics only after positive rapid antigen test or culture 2:

• Amoxicillin is first-line treatment 1
• Duration: 10 days 5

Acute Otitis Media

Antibiotics are indicated for 4, 3:

• Children <2 years of age 4
• Marked symptoms (high fever, intense earache) in children >2 years 4
• Children 6-23 months with bilateral AOM 3
• Children >2 years with bilateral AOM and otorrhea 3

For children >2 years without severe symptoms, watchful waiting with reassessment at 48-72 hours is reasonable 4.

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for viral URTIs - this contributes to antibiotic resistance and causes unnecessary adverse events 2
• Avoid cefixime for sinusitis - it is inactive against pneumococci with decreased penicillin susceptibility 4
• Reserve fluoroquinolones (levofloxacin, moxifloxacin) for complicated sinusitis (frontal, ethmoidal, sphenoidal) or first-line treatment failures 4
• Reassess at 2-3 days if antibiotics are prescribed - if no improvement, consider complications or alternative diagnosis 1