What is the management approach for upper respiratory infections?

Management of Upper Respiratory Tract Infections

Core Principle: Antibiotics Are NOT Indicated for Most URTIs

The vast majority of upper respiratory tract infections are viral and self-limited, requiring only symptomatic management—antibiotics should be withheld unless specific bacterial criteria are met. 1, 2, 3

Initial Assessment and Triage

Distinguish URTI from Pneumonia

• Pneumonia is unlikely if ALL of the following are absent: heart rate >100 bpm, respiratory rate >24 breaths/min, fever >38°C for >3 days, and abnormal chest examination 2
• If pneumonia is suspected based on these criteria, obtain chest radiograph for confirmation 2
• For fever and cough of only 2 days duration without pneumonia signs, provide symptomatic treatment only 2

Common Cold (Acute Rhinitis)

• No antibiotics indicated under any circumstances 1, 2, 3
• Antibiotics do not reduce symptom duration or prevent complications, even with risk factors present 1
• Typical duration: 7-10 days 1

Symptomatic Management Strategies

For Adults

• Analgesics and antipyretics (acetaminophen, NSAIDs) for pain and fever 1, 2, 4
• Zinc supplementation has proven effectiveness 4
• Nasal decongestants (with or without antihistamines) for congestion 2, 4
• Ipratropium nasal spray for rhinorrhea and cough 4
• Intranasal saline irrigation for nasal symptoms 2
• Intranasal corticosteroids for symptomatic relief 2

For Children

• Honey (for children ≥1 year old) for cough 4
• Acetylcysteine for mucus clearance 4
• Nasal saline irrigation 4
• Intranasal ipratropium 4
• Topical ointments containing camphor, menthol, and eucalyptus 4
• Avoid OTC cold medications in children <4 years old 4

Specific Conditions Requiring Antibiotics

Acute Bacterial Rhinosinusitis (ABRS)

Antibiotics are indicated ONLY if:

• Symptoms persist without improvement for >10 days 2, 3
• Severe symptoms (fever ≥39°C, purulent nasal discharge, facial pain) for ≥3 consecutive days 2, 3
• "Double worsening": initial improvement followed by worsening 2

First-line treatment:

• Amoxicillin-clavulanate 1.75-4 g/250 mg per day for adults 5, 2
• Alternative: Cefpodoxime, cefuroxime, or cefdinir 5
• Duration: 7-10 days 5

Group A Streptococcal Pharyngitis

• Confirm diagnosis with rapid antigen test (RAT) before prescribing 1, 2, 3
• Positive RAT justifies antibiotics 1
• Negative RAT with low ARF risk factors does not require antibiotics 1
• Do not treat based on clinical signs alone—no clinical score has adequate predictive value 1

Acute Otitis Media

• Antibiotics indicated for: children <6 months, bilateral AOM in children 6-23 months, bilateral AOM with otorrhea in children >2 years, and high-risk patients 6, 3

Critical Reassessment Timeline

The 72-Hour Rule

• Clinical follow-up is essential with reassessment at 2-3 days 1, 2
• If fever >38°C persists beyond 3 days, consider bacterial superinfection and antibiotic therapy 1, 2
• If symptoms worsen or fail to improve after 72 hours of antibiotics, switch therapy or obtain cultures 5, 2

Common Pitfalls to Avoid

Do NOT Use These as Criteria for Antibiotics

• Purulent or colored (green/yellow) sputum does not indicate bacterial infection 2
• Presence of fever alone in first 2-3 days 1
• Patient or family pressure for antibiotics 1, 2

The Harm-Benefit Calculation

• For acute rhinosinusitis, the number needed to harm (8) exceeds the number needed to treat (18) 2
• Antibiotic adverse events include allergic reactions, C. difficile infection, and contribution to antimicrobial resistance 2, 3

Patient Education Points

Set Appropriate Expectations

• Inform patients that >90% of acute cough illnesses are viral 2
• Explain the self-limited nature (7-10 days typical duration) 1, 4
• Emphasize that antibiotics will not shorten symptom duration for viral infections 1
• Counsel on hand hygiene as the best prevention strategy 4

When to Return for Reassessment

• Fever persisting >3 days 1, 2
• Symptoms worsening after initial improvement 2
• Development of severe symptoms (high fever, severe facial pain, respiratory distress) 5, 2

Role of Pharmacists in URTI Management

• Pharmacists serve as first point of contact for symptomatic management advice 1
• They should educate patients that antibiotics cannot reduce severity or duration of viral URTI symptoms 1
• Provide guidance on appropriate OTC symptomatic treatments 1
• Refer to physician when bacterial infection criteria are met 1