Management of Upper Respiratory Tract Infections
The vast majority of upper respiratory tract infections are viral and self-limited, requiring only symptomatic management—antibiotics should NOT be prescribed for the common cold under any circumstances. 1
Initial Clinical Assessment
When evaluating a patient with upper respiratory symptoms, your primary task is to distinguish viral URIs (which require no antibiotics) from the rare bacterial infections that do warrant antimicrobial therapy.
Pneumonia is unlikely if ALL of the following are absent: 1
- Heart rate >100 bpm
- Respiratory rate >24 breaths/min
- Fever >38°C for >3 days
- Abnormal chest examination findings
If pneumonia is suspected based on these criteria, obtain a chest radiograph for confirmation. 1 For patients with only 2 days of fever and cough without pneumonia signs, provide symptomatic treatment only. 1
Symptomatic Management (First-Line for All Viral URIs)
Recommended symptomatic treatments include: 1
- Analgesics and antipyretics (acetaminophen or NSAIDs) for pain and fever
- Intranasal saline irrigation for nasal congestion
- Intranasal corticosteroids for symptomatic relief
- Zinc supplementation (in adults) 2
- Honey for cough in children ≥1 year old 2
- Ipratropium nasal spray for rhinorrhea 2
Avoid over-the-counter cold medications in children younger than 4 years. 2
When Antibiotics ARE Indicated
Acute Bacterial Rhinosinusitis (ABRS)
Prescribe antibiotics only if: 1
- Symptoms persist without improvement for >10 days, OR
- Severe symptoms are present at onset
First-line treatment: Amoxicillin-clavulanate 1.75-4 g/250 mg per day for adults 1
Group A Streptococcal Pharyngitis
Confirm diagnosis with rapid antigen test (RAT) before prescribing antibiotics. 1 Only positive RAT results justify antibiotic therapy. 1, 3
Acute Otitis Media
Antibiotics are indicated in most cases of acute otitis media. 3 Amoxicillin is the first-line agent for β-lactamase-negative organisms. 4
Epiglottitis
Antibiotics are indicated for confirmed epiglottitis. 3
Critical Reassessment Timeline
Schedule clinical follow-up at 2-3 days. 1 If fever >38°C persists beyond 3 days, consider bacterial superinfection and initiate antibiotic therapy. 1
Common Pitfalls to Avoid
Do NOT prescribe antibiotics for: 1, 3
- Common cold (regardless of symptom duration or severity)
- Influenza
- COVID-19
- Laryngitis
- Acute bronchitis (unless pneumonia is confirmed)
Antibiotics do not reduce symptom duration or prevent complications in viral URIs, even in patients with risk factors. 1 The typical duration of the common cold is 7-10 days regardless of treatment. 1
Patient Education Points
Inform patients that: 1
90% of acute cough illnesses are viral
- Symptoms typically last 7-10 days
- Antibiotics will not shorten symptom duration for viral infections
- Hand hygiene is the best prevention strategy
Role of Pharmacists
Pharmacists serve as the first point of contact for symptomatic management advice and should educate patients that antibiotics cannot reduce severity or duration of viral URTI symptoms. 1 They should refer to a physician only when bacterial infection criteria are met. 1