What are the first line treatment options for viral Upper Respiratory Tract Infections (URTI)?

First-Line Treatment for Viral Upper Respiratory Tract Infections

For viral URTIs, prescribe acetaminophen or ibuprofen for symptomatic relief of pain, fever, and inflammation, and advise patients that antibiotics are not indicated and will not help. 1, 2

Core Symptomatic Management

Analgesics and Antipyretics (First-Line)

• Prescribe acetaminophen or ibuprofen for pain, fever, and inflammation—these are the cornerstone of symptomatic treatment 1, 2
• These medications address the most bothersome symptoms and have the strongest evidence base for viral URTIs 1

Nasal Congestion Relief

• Oral decongestants (pseudoephedrine) may provide symptomatic relief if no contraindications exist (hypertension, cardiac disease, glaucoma) 1
• Topical decongestants (oxymetazoline) can be used but must not exceed 3-5 days to avoid rebound congestion (rhinitis medicamentosa) 1
• Nasal saline irrigation may provide minor improvements in nasal symptoms and is safe for extended use 1, 2

Cough Management

• For dry, bothersome cough, prescribe dextromethorphan or codeine 3, 1, 2
• Do NOT prescribe expectorants, mucolytics, antihistamines, or bronchodilators for acute viral URTI—these lack efficacy in this setting 3, 2

Supportive Care

• Recommend adequate hydration and rest as foundational measures 1, 2

What NOT to Prescribe

Antibiotics Are Contraindicated

• Antibiotics are NOT recommended for uncomplicated viral URTIs—they are ineffective against viral illness, do not provide symptom relief, and contribute to antibiotic resistance 1, 2
• Discolored nasal discharge alone does NOT indicate bacterial infection; it reflects inflammation, not bacterial superinfection 1

Ineffective Medications to Avoid

• Do not prescribe mucolytics, expectorants, or bronchodilators in uncomplicated viral URTI 3, 2
• Newer "non-sedating" antihistamines are relatively ineffective for common cold symptoms 3

When Antibiotics ARE Indicated (Red Flags)

Consider antibiotics only in these specific circumstances:

• Suspected or definite pneumonia (new focal chest signs, dyspnea, tachypnea, fever >4 days) 3
• Age >75 years with fever 3
• Cardiac failure, insulin-dependent diabetes, or serious neurological disorder 3
• High fever persisting beyond 3 days with worsening symptoms suggesting bacterial superinfection 2
• Three or more Centor criteria for streptococcal pharyngitis (only if test/culture positive) 2, 4

First-choice antibiotics when indicated: Amoxicillin or tetracyclines 3

Follow-Up Instructions

Advise Patients to Return If:

• Symptoms persist beyond 3 weeks 3, 1, 2
• Fever exceeds 4 days 3, 1, 2
• Dyspnea worsens 3, 1, 2
• Patient stops drinking or consciousness decreases 3, 1

High-Risk Patients Requiring Closer Monitoring:

• Age ≥65 years 2
• Chronic cardiac or pulmonary diseases 2
• Diabetes mellitus or chronic renal disease 2
• Immunocompromised patients (may require viral testing and specific antiviral therapy) 2

Special Considerations

Antiviral Treatment

• Generally NOT recommended for empirical use 3
• Consider only in high-risk patients with typical influenza symptoms present <2 days during a known influenza epidemic 3, 1

Prevention Strategies

• Influenza vaccination reduces influenza-associated URTIs 1
• Hand hygiene and avoiding close contact with infected individuals 1
• Nasal washing with saline may have prophylactic benefits 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on symptom duration alone—most viral URTIs last 7-10 days without bacterial complications 1, 2
• Do not use topical decongestants beyond 5 days—this creates rebound congestion that is harder to treat than the original symptoms 1
• Do not assume colored nasal discharge means bacterial infection—this is a common misconception that drives inappropriate antibiotic use 1