Treatment of Acute Upper Respiratory Infection
Most acute upper respiratory infections are viral and should be managed with supportive care alone—antibiotics cause more harm than benefit and are not indicated. 1, 2
Initial Assessment: Viral vs. Bacterial
The critical first step is determining whether the infection is viral (vast majority) or one of the few bacterial conditions requiring antibiotics:
Viral URIs (No Antibiotics Needed)
- Common cold, influenza, COVID-19, laryngitis, and acute bronchitis 2
- These account for 75% of all respiratory infections 3
- Antibiotics provide no benefit and increase adverse events and resistance 1, 2
Bacterial Infections (Antibiotics May Be Indicated)
Only specific conditions warrant antibiotic consideration:
Acute Bacterial Rhinosinusitis - requires ALL of the following 1:
- Unilateral or bilateral infraorbital pain worsening when bending forward
- Pulsatile pain peaking in early evening/night
- Failure of initial symptomatic treatment after 7-10 days
- Consider watchful waiting first before antibiotics 1
Group A Streptococcal Pharyngitis 2:
- Use Centor criteria to distinguish from viral pharyngitis 4
- Confirm with rapid antigen test or throat culture 4
Acute Otitis Media 2:
- Primarily in children, requires otoscopic confirmation 4
Supportive Care (First-Line for All Viral URIs)
Symptomatic management includes 1, 5:
- Analgesics (acetaminophen, ibuprofen, naproxen) for pain and fever 1, 5
- Antipyretics for fever control 1
- Saline nasal irrigation 1
- Intranasal corticosteroids for symptom relief 1
- Systemic or topical decongestants as needed 1
- Antihistamines for congestion and runny nose 5
Antibiotic Therapy (When Bacterial Infection Confirmed)
For Acute Bacterial Rhinosinusitis 1:
First-line: Amoxicillin-clavulanate (preferred agent)
- Adults: Standard dosing for 7-10 days 6, 1
- Children: 80 mg/kg/day (amoxicillin component) in 3 doses, maximum 3 g/day 6, 7
Alternative first-line options 6, 1:
- Cefuroxime-axetil (second-generation cephalosporin)
- Cefpodoxime-proxetil (third-generation cephalosporin)
- Pristinamycin (for beta-lactam allergy)
Duration: 7-10 days standard; cefuroxime-axetil and cefpodoxime-proxetil effective in 5 days 6, 1
For Streptococcal Pharyngitis 7, 4:
First-line: Penicillin V or amoxicillin
- Children: Amoxicillin 50-75 mg/kg/day in 2 doses for 10 days 7
- Penicillin V given in two daily doses 4
For Acute Otitis Media (Children) 7, 4:
First-line: Amoxicillin 40-45 mg/kg/day
- Standard dose: 40-45 mg/kg/day divided twice or three times daily 7
- High-dose (90 mg/kg/day) if: 7
- Recent antibiotic use within 4-6 weeks
- High prevalence of penicillin-resistant S. pneumoniae
- Severe infection
- Duration: 5 days for uncomplicated cases 7
Alternative: Amoxicillin-clavulanate 90 mg/6.4 mg per kg per day in areas with high resistance 7
Monitoring and Follow-Up
Assess treatment response at 48-72 hours 1, 7:
- Fever should resolve within 24 hours for pneumococcal infections, 2-4 days for others 6
- Cough may persist longer even with appropriate treatment 6
If no improvement after 48 hours 6, 1:
- Clinical and radiological reassessment necessary 1
- Consider treatment failure or alternative diagnosis 7
- Hospitalization if complications suspected 1
Critical Pitfalls to Avoid
Do not prescribe antibiotics for 1, 2:
- Common cold (viral rhinitis)
- Influenza (consider oseltamivir within 48 hours of symptom onset for high-risk patients) 8
- Acute bronchitis in otherwise healthy adults
- Laryngitis
Avoid these outdated antibiotics for sinusitis 6:
- Aminopenicillins alone (amoxicillin monotherapy)
- Macrolides
- First-generation cephalosporins
- Trimethoprim-sulfamethoxazole
- These have high resistance rates and are no longer recommended 6
Special consideration for children under 5 years 6:
- Amoxicillin-clavulanate or second/third-generation cephalosporins only justified if:
Antiviral Therapy for Influenza
If influenza confirmed and patient presents within 48 hours of symptom onset 8, 9: