What is the treatment for common Upper Respiratory Tract Infections (URTI)?

Treatment of Common Upper Respiratory Tract Infections (URTI)

Common URTIs are predominantly viral and should be managed with symptomatic treatment only; antibiotics are not indicated and do not prevent progression to lower respiratory tract infections. 1, 2

Initial Management Approach

Symptomatic Treatment (First-Line)

• Provide analgesics/antipyretics such as acetaminophen or ibuprofen for pain, fever, and inflammation 2, 3
• Recommend adequate hydration and rest as supportive measures for recovery 2
• Consider nasal saline irrigation for persistent nasal congestion, which may provide minor symptom improvement 2
• Prescribe decongestants (e.g., pseudoephedrine) to temporarily relieve sinus congestion and nasal congestion 4
• For bothersome dry cough, dextromethorphan or codeine may be prescribed 2

What NOT to Prescribe

• Do not prescribe antibiotics for uncomplicated viral URTIs, as they are ineffective against viral illness and will not prevent lower respiratory tract infections 1, 2, 5
• Avoid mucolytics, expectorants, or bronchodilators which have not shown benefit in uncomplicated viral URTIs 2
• Avoid antihistamines and decongestants in children younger than 6 years per FDA guidance 5

When to Consider Antibiotics

Specific Bacterial URTI Conditions Requiring Antibiotics

Acute Bacterial Rhinosinusitis:

• Prescribe antibiotics only if symptoms last longer than 10 days, temperature exceeds 39°C (102.2°F), or symptoms worsen after initial improvement 5
• First-line treatment: amoxicillin-clavulanate, second-generation oral cephalosporins (e.g., cefuroxime-axetil), or third-generation oral cephalosporins (e.g., cefpodoxime-proxetil) 6
• For beta-lactam allergies: pristinamycin or macrolides 6
• Treatment duration: 7-10 days 6

Streptococcal Pharyngitis:

• Prescribe antibiotics only if rapid antigen test or throat culture is positive 5, 7
• First-line treatment: penicillin V given in two daily doses 7
• Treatment duration: 10 days 6

Acute Otitis Media:

• Antibiotics are indicated for: children younger than 6 months, children ages 6-23 months with bilateral AOM, children older than 2 years with bilateral AOM and otorrhea, and high-risk patients 6, 5
• First-line treatment: amoxicillin (80-100 mg/kg/day in three daily doses for children <30 kg) 1
• For treatment failure: amoxicillin-clavulanate provides better coverage against beta-lactamase producing organisms 7

Signs of Bacterial Superinfection

• Consider amoxicillin if high fever (>38.5°C) persists beyond 3 days with bothersome cough 2
• Use amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil for suspected resistant organisms 1, 6

Monitoring and Follow-Up

When to Reassess

• Advise patients to return if: symptoms persist beyond 3 weeks, fever exceeds 4 days, dyspnea worsens, or the patient's condition deteriorates 2
• Consider chest imaging if symptoms persist or worsen to rule out parenchymal lung disease 2

High-Risk Patients Requiring Closer Monitoring

• Patients with risk factors including age ≥65 years, chronic cardiac or pulmonary diseases, diabetes mellitus, or chronic renal diseases require closer monitoring 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically for viral URTIs, as this contributes to antibiotic resistance without clinical benefit 1, 5
• Do not wait for symptoms to worsen before initiating symptomatic treatment; early intervention reduces symptom severity and viral transmission 8
• Do not use antibiotics to "prevent" lower respiratory tract infections, as this approach has been proven ineffective 1
• Recognize that most URTIs are self-limiting and will resolve within 1-3 weeks without specific intervention 1, 2