What is the recommended treatment (Rx) for upper respiratory infection?

Treatment of Upper Respiratory Tract Infections

Most upper respiratory tract infections do not require antibiotics and should be managed with symptomatic treatment alone. 1, 2

First-Line Management: Supportive Care

The cornerstone of URTI management is symptomatic treatment, not antibiotics. 1 This includes:

• Analgesics and antipyretics for pain and fever control 1
• Saline nasal irrigation to clear nasal passages 1
• Intranasal corticosteroids for nasal congestion 1
• Systemic or topical decongestants as needed, but topical decongestants (like oxymetazoline) should be limited to 3 days maximum to prevent rebound congestion 1
• Avoid over-the-counter cough and cold medications in children under 6 years due to lack of efficacy and potential toxicity 1

Most URIs are viral nasopharyngeal infections that resolve in 7-10 days with symptomatic treatment alone. 3, 2

When Antibiotics ARE Indicated

Antibiotics should be reserved for specific bacterial complications, not routine URIs. 1, 4, 2

Acute Bacterial Rhinosinusitis

Antibiotics are appropriate only when specific clinical criteria are met: 1

• Unilateral or bilateral infraorbital pain with pulsatile quality 1
• Failure of initial symptomatic treatment 1
• Severe symptoms at presentation 1
• Development of complications 1

First-line antibiotic choices for bacterial sinusitis:

• Amoxicillin-clavulanate (80 mg/kg/day in children, up to 3 g/day in adults) 5, 1
• Cefuroxime-axetil (second-generation cephalosporin) 5, 1
• Cefpodoxime-proxetil (8 mg/kg/day in two doses for children) 5, 1
• Pristinamycin (particularly for beta-lactam allergy) 5, 1

Duration: 7-10 days standard, though cefuroxime-axetil and cefpodoxime-proxetil have shown efficacy in 5-day regimens. 5, 6

Group A Beta-Hemolytic Streptococcal Pharyngitis

• Antibiotics should only be prescribed if rapid strep test or culture is positive 4, 2
• Amoxicillin is the first-line agent for confirmed streptococcal pharyngitis 7

Acute Otitis Media

• Antibiotics recommended for children under 6 months 8
• Children 6-23 months with bilateral AOM 8
• Children over 2 years with bilateral AOM and otorrhea 8
• High-risk patients regardless of age 8

Critical Conditions NOT Requiring Antibiotics

Do not prescribe antibiotics for: 1, 4, 2

• Common cold 1, 2
• Influenza 1, 2
• COVID-19 1, 2
• Laryngitis 1, 4, 2
• Uncomplicated acute bronchitis 1, 4
• Acute bronchiolitis (unless high fever >38.5°C persisting >3 days or complications present) 5

Monitoring and Reassessment

• Reassess after 2-3 days of antibiotic therapy if prescribed 5, 1
• Primary criterion for improvement is fever resolution 1
• Do not change antibiotics within first 72 hours unless clinical worsening occurs 5
• Consider hospitalization for complications or alternative diagnoses 1

Common Pitfalls to Avoid

• Never use cefixime for respiratory infections where pneumococcal coverage is needed—it is inactive against pneumococci with decreased penicillin susceptibility 1, 6
• Reserve fluoroquinolones (levofloxacin, moxifloxacin) for complicated sinusitis or first-line treatment failure only 5, 1, 6
• Avoid antihistamine-decongestant combinations in young children 1
• Antibiotics are vastly overused for URIs—most are viral and resolve spontaneously 4, 2