What is the first line management for viral Upper Respiratory Tract Infections (URTI)?

First-Line Management of Viral Upper Respiratory Tract Infections

Viral URTIs should be managed with symptomatic treatment only—antibiotics are not indicated, do not prevent progression to lower respiratory tract infections, and should not be prescribed for uncomplicated viral illness. 1

Core Symptomatic Treatment

Analgesics and Antipyretics

• Prescribe acetaminophen or ibuprofen for pain, fever, and inflammation 1
• Both aspirin (500-1000 mg) and acetaminophen (500-1000 mg) demonstrate dose-related efficacy in reducing fever and URTI symptoms in adults, with 1000 mg doses providing superior temperature reduction compared to 500 mg doses 2
• These agents effectively reduce headache, achiness, and feverish discomfort 2

Supportive Measures

• Recommend adequate hydration and rest as foundational supportive care 1, 3
• Nasal saline irrigation may be considered for persistent nasal congestion, providing minor symptom improvement 1, 3

Cough Management

• For bothersome dry cough, prescribe dextromethorphan or codeine 1, 3
• Note that evidence for antitussive efficacy is mixed: one study favored dextromethorphan over placebo while another showed no effect, and codeine was no more effective than placebo in reducing cough symptoms 4

What NOT to Prescribe

Avoid the following as they provide no benefit in uncomplicated viral URTIs:

• Antibiotics—ineffective against viral illness and do not prevent lower respiratory tract infections 1, 5
• Mucolytics, expectorants, or bronchodilators 1
• Antihistamines alone (no more effective than placebo for cough relief) 4

Important caveat: The evidence for most OTC cough preparations is weak and conflicting, with small study numbers and unclear clinical relevance of positive results 4

When to Consider Antibiotics (Bacterial Superinfection)

Red flags suggesting bacterial superinfection requiring antibiotic consideration:

• High fever (>38.5°C) persisting beyond 3 days with bothersome cough—consider amoxicillin 1, 3
• Symptoms lasting longer than 10 days 6
• Symptoms worsening after initial improvement 6

For confirmed bacterial complications:

• Acute bacterial rhinosinusitis: Amoxicillin-clavulanate, second-generation or third-generation oral cephalosporins for 7-10 days 1, 5
• For beta-lactam allergies: pristinamycin or macrolides 1
• Streptococcal pharyngitis: 10-day treatment course (only if test/culture positive) 1, 6
• Acute otitis media in children: Amoxicillin 80-100 mg/kg/day in three divided doses for children <30 kg 1, 5

Monitoring and Follow-Up Instructions

Advise patients to return if:

• Symptoms persist beyond 3 weeks 1
• Fever exceeds 4 days 1
• Dyspnea worsens 1
• Patient's condition deteriorates 1
• Fever does not resolve within 48 hours of treatment 5

Consider chest imaging if symptoms persist or worsen to rule out parenchymal lung disease 1, 3

High-Risk Patients Requiring Closer Monitoring

Patients with the following risk factors need enhanced surveillance:

• Age ≥65 years 1, 3
• Chronic cardiac or pulmonary diseases 1, 3
• Diabetes mellitus 1, 3
• Chronic renal diseases 1, 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically for viral URTIs—this contributes to antibiotic resistance without clinical benefit 1
• Do not use antibiotics to "prevent" lower respiratory tract infections—this approach has been proven ineffective 1
• Remember that most URTIs are self-limiting and resolve within 1-3 weeks without specific intervention 1
• Do not change treatment within the first 72 hours unless the patient's clinical state worsens 5

Special Populations

Immunocompromised patients (HSCT/leukemia): These guidelines do not apply—such patients require viral testing (influenza A/B, RSV, HPIV) and may need specific antiviral therapy including ribavirin 5