Treatment for Upper Respiratory Tract Infections
Most upper respiratory tract infections are viral and should be managed with supportive care alone, as antibiotics cause more harm than benefit and are not indicated. 1, 2
Initial Assessment: Viral vs. Bacterial
The critical first step is distinguishing viral URIs (which require only symptomatic treatment) from bacterial infections (which may warrant antibiotics):
- Viral URIs present with diffuse bilateral nasal symptoms of moderate intensity, congestion with serous discharge, occurring in an epidemic context 3
- Bacterial sinusitis is suggested by symptoms persisting >10 days without improvement, severe symptoms (fever >39°C with purulent discharge for ≥3 consecutive days), or "double sickening" (worsening after initial improvement) 1
- Normal pulmonary auscultation confirms upper (not lower) respiratory tract involvement 4
Supportive Care for Viral URIs (First-Line for Most Cases)
For viral infections, which constitute the majority of URIs, use symptomatic treatment only:
- Analgesics (aspirin or acetaminophen 500-1000 mg) for pain and fever 1, 5
- Saline nasal irrigation to relieve congestion 1, 6
- Intranasal corticosteroids for symptom relief 1
- Systemic or topical decongestants as needed 1
- Zinc for adults 6
- Honey for cough in children ≥1 year old 6
Critical pitfall: Do not prescribe antibiotics for common cold, influenza, COVID-19, or laryngitis 2. Most URIs resolve in 7-10 days with symptomatic treatment alone 7.
Antibiotic Therapy: When and What to Prescribe
Indications for Antibiotics
Antibiotics are indicated ONLY for:
- Acute bacterial rhinosinusitis with symptoms >10 days, severe presentation, or double sickening 1
- Acute otitis media (especially children <6 months) 4
- Group A streptococcal pharyngitis (requires 10 days treatment) 4, 1
- Frontal, ethmoidal, or sphenoidal sinusitis (always requires antibiotics) 3
- Complicated sinusitis with meningeal signs, exophthalmos, palpebral edema, or ocular mobility disorders 3
First-Line Antibiotic Selection
For acute bacterial maxillary sinusitis:
- Amoxicillin-clavulanate is the preferred first-line agent 3, 1, 8
- Alternative options: Cefuroxime-axetil, cefpodoxime-proxetil, or cefotiam-hexetil (NOT cefixime) 3, 1
- For beta-lactam allergies: Pristinamycin, macrolides, or doxycycline 3, 1
For frontal, fronto-ethmoidal, or sphenoidal sinusitis:
- Use amoxicillin-clavulanate or second/third-generation cephalosporins as above 3
- Reserve fluoroquinolones (levofloxacin, moxifloxacin) for complicated cases or first-line treatment failure 3
For streptococcal pharyngitis:
- Amoxicillin is first-line (10 days duration) 1
Treatment Duration and Monitoring
- Standard duration: 7-10 days for sinusitis 3, 4
- Shorter courses: Cefuroxime-axetil and cefpodoxime-proxetil effective in 5 days 3, 1
- Assess response after 2-3 days; fever should resolve within 24 hours for pneumococcal infections 1
- If no improvement after 2-3 days, perform clinical/radiological reassessment and consider hospitalization for complications 1
Pediatric Considerations
For children with maxillary sinusitis:
- Amoxicillin-clavulanate 80 mg/kg/day in three doses (max 3 g/day) 3, 1
- Alternative: Cefpodoxime-proxetil 8 mg/kg/day 1
- Immediate antibiotics recommended for children with risk factors (asthma, heart disease, sickle cell disease) 3
Critical Pitfalls to Avoid
- Do not use first-generation cephalosporins (cephalexin) for respiratory infections—inadequate activity against resistant S. pneumoniae 1
- Do not use cefixime for sinusitis—explicitly excluded from recommended third-generation cephalosporins 3, 1
- Do not prescribe antibiotics for symptoms <10 days unless severe presentation or double sickening pattern 1
- Avoid NSAIDs at anti-inflammatory doses—efficacy not demonstrated 3
- Do not change antibiotics within first 72 hours unless clinical worsening 1