What is the management approach for upper respiratory infections?

Management of Upper Respiratory Infections

Most upper respiratory infections are viral and self-limited, requiring only symptomatic treatment without antibiotics—reserve antibiotics exclusively for confirmed bacterial infections such as streptococcal pharyngitis, acute bacterial sinusitis meeting specific criteria, or acute otitis media in select populations. 1, 2

Initial Assessment

Determine if the infection is above the vocal cords with normal lung sounds to confirm URI rather than lower respiratory tract involvement. 3 Your primary goal is identifying patients who need hospital referral versus those safe for outpatient management. 1, 2

Red Flags Requiring Hospital Referral

Immediately refer patients with any of the following: 1, 3

• Temperature <35°C or ≥40°C
• Heart rate ≥125 beats/min
• Respiratory rate ≥30 breaths/min
• Blood pressure <90/60 mmHg
• Confusion or altered consciousness
• Suspected pleural effusion or cavitation
• Inability to manage at home due to vomiting, social factors, or poor compliance

Risk Stratification

Identify high-risk patients who may develop complications or harbor resistant organisms: 1, 2

• Age >65 years
• Comorbidities (COPD, cardiovascular disease, diabetes, chronic renal/liver failure)
• Recent hospitalization (within past year)
• Recent antibiotic use (within 2-4 weeks)
• Institutionalization

Symptomatic Management (Primary Treatment for Viral URIs)

For the vast majority of URIs, symptomatic treatment is the only appropriate intervention. 2, 4

Proven Effective Treatments in Adults

• Analgesics/antipyretics: Acetaminophen or ibuprofen for pain, fever, and inflammation 2, 4
• Zinc: Effective for reducing cold symptom duration 4
• Nasal decongestants (oral or topical): Provide symptomatic relief if no contraindications exist 2, 4
• Intranasal ipratropium: Effective for rhinorrhea 4

Supportive Measures

• Adequate hydration and rest 2
• Saline nasal irrigation for minor symptom improvement 2, 4

Treatments for Children

Over-the-counter cold medications should NOT be used in children younger than 4 years. 4 Safe options include:

• Acetaminophen or ibuprofen for fever/pain 4
• Honey for cough (only in children ≥1 year old) 4
• Nasal saline irrigation 4
• Topical ointments containing camphor, menthol, and eucalyptus 4

When Antibiotics Are Indicated

Antibiotics are ineffective for viral URIs and contribute to resistance—prescribe only for confirmed bacterial infections. 1, 2

Specific Bacterial Infections Requiring Antibiotics

Streptococcal pharyngitis: Only prescribe antibiotics with positive rapid strep test or culture 1, 5

Acute bacterial sinusitis: Consider antibiotics only if: 5

• Symptoms persist >10 days without improvement, OR
• Temperature >39°C (102.2°F), OR
• Symptoms worsen after initial improvement ("double worsening")
• Otherwise, wait an additional 7 days before prescribing 5

Acute otitis media: Antibiotics indicated for: 5

• All children <6 months
• Children 6-23 months with bilateral AOM
• Children >2 years with bilateral AOM and otorrhea
• High-risk patients

First-Line Antibiotic Selection

Amoxicillin is the first-line antibiotic for most bacterial URIs requiring treatment. 3, 6 It is indicated for susceptible (β-lactamase-negative) organisms including Streptococcus species, S. pneumoniae, Staphylococcus spp., and H. influenzae. 6

Amoxicillin-clavulanate is preferred when β-lactamase-producing organisms are suspected or in patients with recent antibiotic exposure. 3

Respiratory fluoroquinolones (levofloxacin, moxifloxacin) are reserved for recurrent or complicated infections, or when first-line therapy fails. 3

Follow-Up and Safety Netting

Advise patients to return if: 2

• Symptoms persist beyond 3 weeks
• Fever exceeds 4 days
• Dyspnea worsens
• Patient stops drinking or consciousness decreases

For bacterial infections treated with antibiotics, reassess within 48-72 hours if no clinical improvement occurs. 3, 2

Most uncomplicated URIs should show improvement within 3-5 days. 3

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for viral URIs—this is ineffective and drives resistance 1, 2
• Do not assume purulent nasal discharge indicates bacterial infection—discoloration reflects inflammation, not bacterial etiology 2
• Do not rely on imaging to diagnose acute bacterial sinusitis—diagnosis is clinical 2
• Do not use clinical signs alone to distinguish viral from bacterial infection—apply stringent diagnostic criteria and appropriate testing 1
• Do not delay appropriate antibiotic therapy when truly indicated for confirmed bacterial infections 2

Prevention

Hand hygiene is the most effective prevention strategy for URI transmission. 4 Counsel patients on proper handwashing technique to reduce viral spread.