What medications can be given for upper respiratory infections?

Treatment of Upper Respiratory Tract Infections

Most upper respiratory tract infections are viral and should be managed with supportive care alone—antibiotics cause more harm than benefit and are not indicated unless specific bacterial complications develop. 1, 2, 3

Initial Management: Supportive Care First-Line

The cornerstone of URTI management is symptomatic treatment, not antibiotics 2:

• Analgesics (acetaminophen, NSAIDs) for pain relief 2
• Antipyretics for fever control 2
• Saline nasal irrigation for nasal congestion 2
• Intranasal corticosteroids for symptom relief 2
• Systemic or topical decongestants as needed for congestion 1, 2

Important Decongestant Precautions

• Topical decongestants (oxymetazoline) should be used for no more than 3 days to avoid rhinitis medicamentosa (rebound congestion) 1
• Avoid OTC cough and cold medications in children under 6 years due to lack of efficacy and potential toxicity 1
• Use caution with decongestants in first trimester pregnancy due to fetal heart rate changes 1

When Antibiotics ARE Indicated

Acute Bacterial Rhinosinusitis

Antibiotics are appropriate only in specific circumstances 1, 2:

Clinical criteria requiring antibiotics:

• Unilateral or bilateral infraorbital pain that worsens when bending forward 1, 2
• Pulsatile pain peaking in early evening/night 1
• Failure of initial symptomatic treatment after 7-10 days 1
• Severe symptoms: fever >39°C, severe facial pain for ≥3 consecutive days 2
• Complications: meningeal signs, exophthalmos, palpebral edema, ocular mobility disorders 1

First-line antibiotic choices by location:

• Maxillary sinusitis: Amoxicillin-clavulanate, cefuroxime-axetil, cefpodoxime-proxetil, or pristinamycin (if beta-lactam allergy) 1, 2
• Frontal, ethmoidal, or sphenoidal sinusitis: Same as above, OR respiratory fluoroquinolones (levofloxacin, moxifloxacin) for complicated cases 1
• Duration: 7-10 days standard; cefuroxime-axetil and cefpodoxime-proxetil effective in 5 days 1, 2

Critical exclusion: Cefixime is specifically NOT recommended for sinusitis due to inactivity against pneumococci with decreased penicillin susceptibility 4

Streptococcal Pharyngitis

• First-line: Amoxicillin for Group A beta-hemolytic streptococcal pharyngitis 2, 5
• Alternative: Oral cephalosporins (cefaclor, cephalexin) or macrolides if penicillin allergy 5
• Duration: 10-14 days to prevent acute rheumatic fever 5

Acute Otitis Media

• Antibiotics recommended in children under 2 years 4
• May withhold in children over 2 years except with marked symptoms 4

Monitoring and Treatment Failure

Reassess after 2-3 days of antibiotic therapy 2:

• Primary criterion: fever resolution (may take 24 hours for pneumococcal, 2-4 days for other etiologies) 1
• If no improvement: perform clinical and radiological reassessment 2
• Consider hospitalization for complications or underlying diagnoses 1, 2

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics for: common cold, influenza, COVID-19, laryngitis, or uncomplicated acute bronchitis 2, 3
• Do NOT use cefixime for respiratory infections where pneumococcal coverage is needed 4
• Do NOT obtain antibiotics without prescription—62% global rate of non-prescription antibiotic dispensing contributes to resistance 1
• Do NOT use antihistamine-decongestant combinations in young children—they are ineffective for viral URTIs 1
• Reserve fluoroquinolones for complicated sinusitis or first-line treatment failure only 1

Pediatric Dosing Specifics

For children requiring antibiotics for sinusitis 1:

• Amoxicillin-clavulanate: 80 mg/kg/day (maximum 3 g/day) in divided doses
• Cefpodoxime-proxetil: 8 mg/kg/day
• Only justified in children <5 years if inadequate H. influenzae type b vaccination (<3 injections) or coexisting purulent otitis media 1