Management of Upper Respiratory Infection
Most upper respiratory infections are viral and should be managed with symptomatic treatment only—antibiotics are not indicated and will not prevent progression to lower respiratory tract infections. 1
Initial Assessment
When evaluating a patient with URI symptoms, focus on distinguishing viral URI from conditions requiring antibiotics:
- Assess for pneumonia indicators: new focal chest signs, dyspnea, tachypnea, pulse >100 bpm, or fever >4 days 2
- Check for bacterial sinusitis criteria: symptoms persisting >10 days, high fever with purulent discharge and facial pain for ≥3 consecutive days, or "double sickening" (worsening after initial improvement) 1
- Evaluate severity markers: fever >37.8°C, tachycardia, tachypnea >25/min suggest pneumonia rather than simple URI 3
- Consider CRP testing if pneumonia suspected: CRP <20 mg/L with symptoms >24 hours makes pneumonia highly unlikely; CRP >100 mg/L makes it likely 2
Critical pitfall: Purulent nasal discharge alone does NOT indicate bacterial infection—it reflects inflammation, not bacterial etiology 4
Symptomatic Treatment (First-Line Management)
Provide analgesics and antipyretics for all patients with uncomplicated URI: 1, 4
- Acetaminophen or ibuprofen for pain, fever, and inflammation 4
- Adequate hydration and rest as supportive measures 4
- Saline nasal irrigation for minor nasal symptom relief 4
- Oral decongestants if no contraindications exist 4
- Cough suppressants (dextromethorphan or codeine) for bothersome cough interfering with sleep 5, 6
When Antibiotics Are NOT Indicated
Do not prescribe antibiotics for: 1, 7
- Common cold 7
- Viral pharyngitis 7
- Acute bronchitis in healthy adults 3, 7
- Influenza 7
- Laryngitis 7
- Acute rhinosinusitis <10 days without severe features 1
Rationale: Antibiotics are ineffective against viral infections, contribute to resistance, cause adverse events, and will not prevent progression to lower respiratory tract infections 1, 4
When Antibiotics ARE Indicated
Prescribe antibiotics only for documented bacterial infections: 1, 7
- Acute bacterial rhinosinusitis meeting criteria above 1
- Group A streptococcal pharyngitis with positive rapid test or culture 7
- Acute otitis media in specific populations 7
- Suspected pneumonia based on clinical and laboratory findings 3
Follow-Up and Safety Netting
Instruct patients to return if: 4
- Symptoms persist beyond 3 weeks 4
- Fever exceeds 4 days 4
- Dyspnea develops or worsens 4
- Patient stops drinking or consciousness decreases 4
Reassess within 48-72 hours if bacterial infection was suspected and antibiotics initiated 4
Special Populations Requiring Closer Monitoring
Identify high-risk patients: 4
- Age >65 years 4
- Comorbidities (COPD, cardiovascular disease, diabetes) 4
- Recent antibiotic use 4
- Social factors (inability to comply, extreme poverty, dependency) 4
Common Management Errors to Avoid
- Prescribing antibiotics for viral URIs (most common error) 4, 7
- Assuming purulent discharge indicates bacterial infection 4
- Using imaging studies to diagnose acute bacterial sinusitis 4
- Delaying antibiotics when truly indicated for bacterial infections 4
- Using over-the-counter cold medications in children <6 years 8