What is the treatment for an Upper Respiratory Infection (URI)?

Treatment for Upper Respiratory Tract Infections

Most upper respiratory tract infections are viral and should be managed with supportive care alone—antibiotics are not indicated and cause more harm than benefit. 1, 2

Initial Assessment: Viral vs. Bacterial

The critical first step is distinguishing viral URIs (which comprise the vast majority) from specific bacterial infections that may warrant antibiotics. 3, 2

Key principle: URIs occur above the vocal cords with normal pulmonary auscultation and are predominantly viral. 1, 2

When Antibiotics Are NOT Indicated

• Common cold/viral rhinitis: No antibiotics—purely symptomatic management 2, 4
• Acute bronchitis in healthy adults: No antibiotics, even with fever present 1
• Viral pharyngitis: No antibiotics unless confirmed bacterial (see below) 3, 5

When to Consider Bacterial Infection

Antibiotics should only be considered for three specific bacterial URIs:

1. Acute bacterial rhinosinusitis - requires one of three patterns: 1, 2

   • Persistent symptoms >10 days without improvement
   • Severe symptoms: fever ≥39°C with purulent nasal discharge for ≥3 consecutive days
   • "Double sickening": worsening after initial improvement

2. Streptococcal pharyngitis - requires positive rapid test or culture AND ≥2 Centor criteria: 3, 5

   • Fever
   • Tonsillar exudate/swelling
   • Tender anterior cervical lymphadenopathy
   • Absence of cough

3. Acute otitis media - requires middle ear effusion plus signs of inflammation 3

Recommended Supportive Care (First-Line for Viral URI)

For all viral URIs, the following symptomatic treatments are recommended: 1, 2

• Analgesics/antipyretics: Acetaminophen or ibuprofen for pain, fever, and inflammation 2, 6
• Adequate hydration and rest 2
• Saline nasal irrigation for persistent nasal congestion 1, 2
• Intranasal corticosteroids for symptom relief 1
• Systemic or topical decongestants as needed 1
• Dextromethorphan or codeine for bothersome dry cough 2

What NOT to Prescribe

• Antibiotics for uncomplicated viral URIs - ineffective and will not prevent progression to lower respiratory tract infections 2
• Mucolytics, expectorants, or bronchodilators - no proven benefit 2

Antibiotic Therapy (Only for Confirmed Bacterial Infections)

Acute Bacterial Rhinosinusitis (symptoms >10 days)

First-line: Amoxicillin-clavulanate 1, 2

• Provides coverage against penicillin-resistant S. pneumoniae, H. influenzae, and M. catarrhalis 1

Alternatives: 1, 2

• Second-generation cephalosporins (cefuroxime-axetil)
• Third-generation cephalosporins (cefpodoxime-proxetil, cefotiam-hexetil, but NOT cefixime)
• Doxycycline (if amoxicillin-clavulanate contraindicated)
• Respiratory fluoroquinolones (levofloxacin or moxifloxacin)

Duration: 7-10 days 1, 2

Important caveat: First-generation cephalosporins (cephalexin) should NOT be used due to inadequate activity against penicillin-resistant S. pneumoniae 1

Streptococcal Pharyngitis

First-line: Amoxicillin or Penicillin V (two daily doses) 1, 5

Duration: 10 days 2, 5

Acute Otitis Media

First-line: Amoxicillin 80-100 mg/kg/day in three divided doses (children <30 kg) 2, 7

Alternative: Amoxicillin-clavulanate for treatment failures or β-lactamase-producing organisms 5

Monitoring and Reassessment

Assess therapeutic response after 2-3 days of antibiotic treatment: 1

• Primary criterion: fever resolution (typically within 24 hours for pneumococcal infections, 2-4 days for others) 1
• Cough may persist longer and should not be the sole indicator of treatment failure 1

Red flags requiring reassessment or hospitalization: 2

• Symptoms persist beyond 3 weeks
• Fever exceeds 4 days
• Dyspnea worsens
• Patient's condition deteriorates

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically for viral URIs - this contributes to antibiotic resistance without clinical benefit 2
• Do not use antibiotics to "prevent" lower respiratory tract infections - proven ineffective 2
• Do not assume all cephalosporins are equivalent - first-generation agents lack adequate respiratory pathogen coverage 1
• Do not treat pharyngitis empirically - always confirm with testing before prescribing antibiotics 3
• Macrolides and oral third-generation cephalosporins are poor choices due to high pneumococcal resistance rates 3

Special Populations

High-risk patients (age ≥65, chronic cardiac/pulmonary disease, diabetes, chronic renal disease) require closer monitoring but the same initial approach applies. 2

Children <3 years with pneumonia: Amoxicillin 80-100 mg/kg/day remains first-line; hospitalization preferred for β-lactam allergies. 3