What are the management options for upper respiratory tract infections?

Management of Upper Respiratory Tract Infections

The vast majority of upper respiratory tract infections are viral and self-limited—withhold antibiotics unless specific bacterial criteria are met, and focus on symptomatic management with analgesics, intranasal saline, and intranasal corticosteroids. 1

Initial Assessment and Triage

Determine if this is viral (98-99.5% of cases) or bacterial infection before considering antibiotics. 1

• No antibiotics are indicated for the common cold under any circumstances—antibiotics do not reduce symptom duration or prevent complications even with risk factors present 1
• Typical duration of the common cold is 7-10 days, and approximately 90% of acute cough illnesses are viral 1
• Pneumonia is unlikely if ALL of the following are absent: heart rate >100 bpm, respiratory rate >24 breaths/min, fever >38°C for >3 days, and abnormal chest examination 1
• If pneumonia is suspected based on these criteria, obtain chest radiograph for confirmation 1

Symptomatic Management (First-Line for All Viral URTIs)

Provide symptomatic treatment for all patients regardless of etiology: 2, 1

• Analgesics and antipyretics (acetaminophen, NSAIDs) are recommended for pain and fever 2, 1
• Intranasal saline irrigation is recommended for nasal symptoms 1
• Intranasal corticosteroids are recommended for symptomatic relief 1
• Adequate hydration, warm facial packs, and sleeping with head elevated provide supportive benefit 3

Specific Conditions Requiring Antibiotics

Acute Bacterial Rhinosinusitis (ABRS)

Antibiotics are indicated only if: 1, 3

• Symptoms persist without improvement for >10 days, OR
• Severe symptoms are present (fever >39°C with purulent discharge for ≥3 consecutive days), OR
• "Double sickening" pattern (worsening after initial improvement from viral URI) 3

First-line treatment for ABRS is amoxicillin-clavulanate 875/125 mg twice daily for adults (or 1.75-4 g/250 mg per day). 1, 3 For children, use amoxicillin 45 mg/kg/day in 2 divided doses for standard therapy, or high-dose amoxicillin 80-90 mg/kg/day in 2 divided doses for high-risk children (age <2 years, daycare attendance, recent antibiotic use). 3

Alternative first-line options for penicillin allergy: 2, 3

• Second-generation cephalosporins: cefuroxime-axetil 2, 3
• Third-generation cephalosporins: cefpodoxime-proxetil, cefdinir 2, 3
• Pristinamycin for beta-lactam allergy 2

Reserve fluoroquinolones (levofloxacin, moxifloxacin) for: 2, 3

• Frontal, ethmoidal, or sphenoidal sinusitis (high complication risk) 2
• Failure of first-line antibiotic therapy after 3-5 days 3
• Severe penicillin allergy when cephalosporins are contraindicated 3

Treatment duration is 7-10 days, though some cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) are effective in 5-day courses. 2

Group A Streptococcal Pharyngitis

Confirm diagnosis with rapid antigen test (RAT) before prescribing antibiotics—positive RAT justifies antibiotics. 2, 1 The streptococcal origin of pharyngitis cannot be determined by clinical signs or scores with adequate predictive value; only microbiological tests are reliable. 2

• A negative RAT with low risk factors for acute rheumatic fever (ARF) does not usually require antibiotic therapy 2
• In rare high-risk situations (individual history of ARF, age 5-25 years with poor social conditions, stays in streptococcal-endemic regions), a negative RAT should be followed by specimen culture 2

Antibiotic treatment should be promptly initiated after confirmation of GAS-pharyngitis to prevent ARF. 2 Penicillin G has demonstrated efficacy (Grade A evidence). 2

Complicated Sinusitis Requiring Hospitalization

Clinical signs suggestive of complicated sinusitis require hospitalization, bacteriological testing, and parenteral antibiotic therapy: 2

• Meningeal syndrome 2
• Exophthalmos 2
• Palpebral edema 2
• Ocular mobility disorders 2
• Severe pain preventing sleep 2

Critical Reassessment Timeline

Clinical follow-up is essential with reassessment at 2-3 days for most URTIs, or 3-5 days for sinusitis on antibiotics. 2, 1, 3

• If fever >38°C persists beyond 3 days, consider bacterial superinfection and antibiotic therapy 2, 1
• If no improvement after 3-5 days of antibiotic treatment, switch to different antibiotic or re-evaluate diagnosis 3
• By 7 days of treatment, most patients with bacterial sinusitis should feel better 3

Patient Education Points

Inform patients that: 1

• 90% of acute cough illnesses are viral and self-limited (7-10 days typical duration) 1

• Antibiotics will not shorten symptom duration for viral infections 1
• They should return if fever does not resolve within 48 hours of starting antibiotics 2
• Cough may last longer than the duration of antibiotic treatment 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral rhinosinusitis lasting <10 days unless severe symptoms are present 3
• Do not use azithromycin or other macrolides as first-line therapy for sinusitis due to 20-25% resistance rates 3
• Do not assume mucus color alone indicates bacterial infection—color reflects neutrophils, not bacteria 3
• Do not continue ineffective antibiotic therapy beyond 3-5 days without reassessment 3
• Do not use clindamycin as monotherapy for sinusitis—it lacks activity against H. influenzae and M. catarrhalis 3