What is the initial treatment approach for a patient presenting with an upper respiratory infection?

SOAP Note for Upper Respiratory Infection

Subjective

Document the following key elements:

• Duration and progression of symptoms – Critical for distinguishing viral from bacterial etiology 1
• Specific symptoms present: nasal congestion, rhinorrhea (clear vs. purulent), sore throat, cough, fever (document temperature if >39°C), ear pain, facial pain/pressure 2, 3
• Timing: Symptoms <10 days suggest viral; >10 days without improvement or worsening after initial improvement suggest bacterial 1, 4
• Recent antibiotic use within past 4-6 weeks 2
• Sick contacts and environmental exposures 2

Objective

Physical examination findings to document:

• Vital signs: Temperature (fever >38.5°C for >3 days increases bacterial likelihood) 2, 1
• Nasal examination: Quality of discharge (clear vs. purulent), mucosal edema 2
• Oropharynx: Erythema, exudate, tonsillar enlargement 3
• Tympanic membranes: Assess for acute otitis media in children 1, 5
• Sinus tenderness: Maxillary or frontal sinus percussion 2
• Lung auscultation: Must be normal to confirm URTI vs. lower respiratory tract infection 2

Assessment

Most upper respiratory tract infections are viral, self-limiting, and resolve without antibiotics 1, 3. The diagnosis should specify:

• Acute viral rhinosinusitis (common cold) if symptoms <10 days 2, 1
• Acute bacterial rhinosinusitis if symptoms persist >10 days without improvement, severe symptoms (fever ≥39°C, purulent discharge) for ≥3 consecutive days, or "double worsening" (initial improvement followed by worsening) 1, 4
• Acute pharyngitis – specify viral vs. streptococcal based on testing 3, 4

Plan

For Viral URTI (Common Cold) – No Antibiotics Indicated

Symptomatic management is the cornerstone of treatment 2, 1:

• Analgesics/antipyretics: Acetaminophen or ibuprofen for pain and fever 1, 6
• Intranasal corticosteroids (mometasone, fluticasone propionate, or fluticasone furoate once daily) for symptom relief in acute post-viral rhinosinusitis if needed 2
• Decongestants: Short-term use (≤5 days) of topical decongestants like oxymetazoline to avoid rhinitis medicamentosa 2
• Antihistamines: First-generation antihistamines may provide modest benefit for rhinorrhea 2
• Avoid antibiotics – they do not hasten recovery, prevent complications, or provide benefit in viral infections 1, 4

For Acute Bacterial Rhinosinusitis – When Antibiotics Are Indicated

Antibiotics should be reserved for specific clinical scenarios 1:

• Symptoms persisting >10 days without improvement 1, 4
• Severe symptoms (fever ≥39°C, purulent nasal discharge, facial pain) for ≥3 consecutive days 1
• Worsening symptoms after initial improvement 1

First-line antibiotic choice for adults:

• Amoxicillin-clavulanate 875 mg/125 mg every 12 hours for 7-10 days is preferred over amoxicillin alone due to coverage of beta-lactamase-producing H. influenzae and M. catarrhalis 2, 1, 7
• Alternative: High-dose amoxicillin 1.5-4 g/day if no recent antibiotic use 2

For patients with recent antibiotic use (within 4-6 weeks) or moderate disease:

• Respiratory fluoroquinolone (levofloxacin, moxifloxacin) or high-dose amoxicillin-clavulanate 4 g/250 mg per day 2

For children:

• Amoxicillin-clavulanate 80-100 mg/kg/day (of amoxicillin component) in three divided doses for children <3 years 2, 1
• For children >3 years with atypical bacterial coverage needed, consider macrolides 2

Reassessment and Follow-up

• Assess therapeutic efficacy within 48-72 hours 2, 1
• If no improvement or worsening at 72 hours, consider switching antibiotics or reevaluating diagnosis 2, 1
• Duration of antibiotic therapy: 5-7 days for most cases 2

Patient Education

• Expected course: Viral URTIs typically resolve in 7-10 days 8, 9
• Red flags for return: High fever persisting >3 days, severe worsening of symptoms, difficulty breathing 2, 1
• Antibiotic stewardship: Explain why antibiotics are not indicated for viral infections to manage expectations and reduce inappropriate use 1, 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral URTIs – this contributes significantly to antibiotic resistance and provides no clinical benefit 1, 4
• Avoid changing antibiotics before 72 hours unless clinical deterioration occurs 2, 1
• Be aware that amoxicillin-clavulanate has higher gastrointestinal side effects compared to amoxicillin alone 1, 5
• Do not use over-the-counter cough and cold medications in children <6 years per FDA guidance 1