What is the recommended treatment for an upper respiratory tract infection?

Treatment of Upper Respiratory Tract Infections

Most upper respiratory tract infections are viral and should be managed with symptomatic treatment alone—antibiotics cause more harm than benefit and are only indicated for confirmed bacterial infections such as streptococcal pharyngitis, acute bacterial rhinosinusitis meeting specific criteria, or acute otitis media in select populations. 1, 2

Initial Approach: Distinguish Viral from Bacterial Infection

The critical first step is determining whether the infection is viral (no antibiotics) or bacterial (antibiotics indicated). 2

Symptomatic Treatment for Viral URTIs (First-Line)

For the vast majority of URTIs, which are viral, provide:

• Analgesics (acetaminophen, ibuprofen, naproxen) for pain 1, 2
• Antipyretics for fever 1, 2
• Saline nasal irrigation for congestion 1, 2
• Intranasal corticosteroids for symptom relief 1, 2
• Systemic or topical decongestants as needed 1, 2

Common pitfall: Do not prescribe antibiotics for the common cold, acute bronchitis in healthy adults (even with fever or purulent sputum), influenza, COVID-19, or laryngitis—these are viral and antibiotics provide no benefit. 2, 3

When Antibiotics ARE Indicated

1. Streptococcal Pharyngitis

• Only prescribe antibiotics if rapid antigen test (RAT) or culture is positive for Group A Streptococcus 4
• Clinical signs alone cannot reliably diagnose streptococcal pharyngitis 4
• First-line treatment: Amoxicillin 1
• A negative RAT in low-risk patients does not require antibiotics 4

2. Acute Bacterial Rhinosinusitis

Antibiotics are indicated when any one of these criteria is met:

• Symptoms persisting >10 days without improvement (most common indication) 1
• Severe symptoms: Fever >39°C (102.2°F) with purulent nasal discharge or facial pain for ≥3 consecutive days 1
• "Double sickening": Worsening after initial improvement following a typical viral URI 1
• Complications: Meningeal signs, exophthalmos, palpebral edema, ocular mobility disorders, severe pain preventing sleep 4

First-line antibiotic: Amoxicillin-clavulanate 4, 1, 2

Alternative options:

• Second-generation cephalosporins: cefuroxime-axetil 4, 2
• Third-generation cephalosporins: cefpodoxime-proxetil, cefotiam-hexetil (but NOT cefixime) 4, 1
• Pristinamycin for beta-lactam allergy 4, 2
• Doxycycline or respiratory fluoroquinolones (levofloxacin, moxifloxacin) if amoxicillin-clavulanate is contraindicated 1

Duration: 7-10 days (cefuroxime-axetil and cefpodoxime-proxetil effective in 5 days) 4, 1

Important caveat: Fluoroquinolones should be reserved for complicated sinusitis (frontal, ethmoidal, sphenoidal) or first-line treatment failure. 4

3. Acute Otitis Media

• Antibiotics indicated in children <6 months, children 6-23 months with bilateral AOM, children >2 years with bilateral AOM and otorrhea, and high-risk patients 1, 5
• First-line treatment: Amoxicillin-clavulanate 45 mg/kg/day divided every 12 hours for 10 days 6

Specific Dosing for Amoxicillin-Clavulanate

Adults

• For respiratory tract infections: 875 mg/125 mg every 12 hours OR 500 mg/125 mg every 8 hours 6
• Take at the start of meals to minimize GI intolerance and enhance clavulanate absorption 6

Pediatric Patients (≥12 weeks/3 months)

• For sinusitis, otitis media, lower respiratory infections: 45 mg/kg/day divided every 12 hours 6
• Less severe infections: 25 mg/kg/day divided every 12 hours 6
• The every 12-hour regimen is preferred as it causes significantly less diarrhea 6

Monitoring Treatment Response

• Assess efficacy after 2-3 days of antibiotic treatment 1, 2
• Fever should resolve within 24 hours for pneumococcal infections, 2-4 days for other bacterial etiologies 1
• If no improvement occurs, perform clinical and radiological reassessment and consider hospitalization for complications 1, 2

Critical pitfall: Cough may persist longer and should not be used as the sole indicator of treatment failure. 1

What NOT to Use

• First-generation cephalosporins (e.g., cephalexin): Inadequate activity against penicillin-resistant S. pneumoniae and should never be used for respiratory infections 1
• Aminopenicillins alone, macrolides, cotrimoxazole: No longer recommended due to resistance 4
• NSAIDs at anti-inflammatory doses: Efficacy not demonstrated for sinusitis 4