What is the treatment approach for upper respiratory infections?

Treatment of Upper Respiratory Infections

Most upper respiratory infections are viral and require only symptomatic treatment—antibiotics should NOT be prescribed for the common cold, influenza, COVID-19, or uncomplicated laryngitis. 1, 2, 3

Initial Management: Symptomatic Treatment for All Patients

The cornerstone of URI management is supportive care, regardless of whether antibiotics are eventually needed 2:

• Analgesics/antipyretics: Acetaminophen or NSAIDs (ibuprofen, naproxen) for pain and fever 1, 2
• Saline nasal irrigation: For symptomatic relief of congestion 1, 2
• Intranasal corticosteroids: Reduce mucosal inflammation and may decrease need for antibiotics 1, 2
• Decongestants: Systemic or topical as needed, but limit topical decongestants (oxymetazoline) to 3 days maximum to avoid rebound congestion 2
• Adequate hydration, rest, warm facial packs, sleeping with head elevated 1

Critical pitfall: Avoid over-the-counter cough and cold medications in children under 6 years due to lack of efficacy and potential toxicity 2

When Antibiotics ARE Indicated: Acute Bacterial Sinusitis

Antibiotics are appropriate only when acute bacterial sinusitis is confirmed by one of three clinical patterns 1:

1. Persistent symptoms ≥10 days without clinical improvement
2. Severe symptoms for ≥3 consecutive days: Fever >39°C, purulent nasal discharge, facial pain
3. "Double sickening": Worsening symptoms after initial improvement from a viral URI

First-Line Antibiotic Selection

For uncomplicated maxillary sinusitis (most common type):

• Amoxicillin 500 mg twice daily for mild disease OR 875 mg twice daily for moderate disease 1, 4
• Amoxicillin-clavulanate 875 mg/125 mg twice daily is preferred if recent antibiotic exposure, moderate-to-severe disease, or risk factors present 1
• Duration: 5-10 days, typically until symptom-free for 7 days 1

For penicillin-allergic patients:

• Second-generation cephalosporins: Cefuroxime-axetil 1, 5
• Third-generation cephalosporins: Cefpodoxime-proxetil or cefdinir (NOT cefixime, which lacks pneumococcal coverage) 1, 5
• For severe beta-lactam allergy: Levofloxacin 500 mg once daily for 10-14 days 1

Critical pitfall: Azithromycin and other macrolides should NOT be used due to 20-25% resistance rates 1

Pediatric Dosing

• Standard therapy: Amoxicillin 45 mg/kg/day in 2 divided doses 1
• High-dose therapy (for areas with resistant S. pneumoniae or risk factors): Amoxicillin 80-90 mg/kg/day in 2 divided doses 1
• Amoxicillin-clavulanate: 80-90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses for children <2 years, daycare attendance, or recent antibiotic use 1

Treatment Failure Protocol

Reassess at 3-5 days (72 hours in pediatrics) if no improvement 1:

• Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate, max 2 g every 12 hours) 1
• Alternative: Respiratory fluoroquinolones (levofloxacin 500-750 mg once daily or moxifloxacin) for treatment failures or complicated sinusitis 1
• Consider: Complications, alternative diagnosis, or ENT referral if symptoms worsen 1

Complicated Sinusitis (Frontal, Ethmoidal, Sphenoidal)

Reserve fluoroquinolones (levofloxacin or moxifloxacin) for these anatomic locations due to potential for serious complications 1, 5

Adjunctive Therapies for Bacterial Sinusitis

• Intranasal corticosteroids: Recommended as adjunct to antibiotics in acute and chronic sinusitis 1
• Short-term oral corticosteroids: May be reasonable for marked mucosal edema or failure to respond to initial treatment (typically 5 days) 1

Critical pitfall: Corticosteroids should never be used as monotherapy—antibiotics are necessary to treat the underlying bacterial infection 1

Watchful Waiting Option

For adults with uncomplicated acute bacterial sinusitis, watchful waiting without immediate antibiotics is appropriate when follow-up can be assured, with antibiotics started if no improvement by 7 days or worsening at any time 1

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics for common cold, influenza, COVID-19, or laryngitis 2, 3
• Do NOT use cefixime for respiratory infections—it lacks activity against pneumococci with decreased penicillin susceptibility 5, 2
• Do NOT use fluoroquinolones routinely—reserve for treatment failures, complicated sinusitis, or multi-drug resistant organisms to prevent resistance 1
• Ensure adequate treatment duration (minimum 5 days, typically 7-10 days) to prevent relapse 1
• Reassess patients who fail to improve within 3-5 days to avoid treatment failure 1