What is the first line of treatment for upper respiratory tract infections (URTI)?

Upper Respiratory Tract Infection Management

First-Line Treatment: Symptomatic Care for Viral URTIs

Most upper respiratory tract infections are viral and should be managed with supportive care alone—antibiotics cause more harm than benefit in these cases. 1, 2

Symptomatic Treatment Approach

• Analgesics (acetaminophen or NSAIDs) for pain and fever relief 1, 2
• Antipyretics for fever management 1, 2
• Saline nasal irrigation for symptom relief and mucus clearance 1, 2
• Intranasal corticosteroids to reduce mucosal inflammation and improve symptom resolution 1, 2
• Systemic or topical decongestants as needed for congestion 1, 2

The European Society of Clinical Microbiology and Infectious Diseases emphasizes that URTIs occur above the vocal cords with normal pulmonary auscultation and are predominantly viral. 1 Research confirms that acute respiratory tract infections account for billions in healthcare costs, yet most are inappropriately treated with antibiotics despite being viral in origin. 3, 4

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When Antibiotics ARE Indicated

Acute Bacterial Rhinosinusitis

Antibiotics should only be prescribed when one of three diagnostic criteria is met: 1

1. Persistent symptoms ≥10 days without clinical improvement 1
2. Severe symptoms (fever ≥39°C with purulent nasal discharge and facial pain) for ≥3 consecutive days 1
3. "Double sickening" pattern—worsening after initial improvement from a viral URI 1

First-line antibiotic: Amoxicillin-clavulanate for maxillary sinusitis when antibiotics are indicated. 1, 2 The Infectious Diseases Society of America recommends this specifically for patients with unilateral or bilateral infraorbital pain that increases when bending forward, pulsatile pain peaking in early evening/night, failure of initial symptomatic treatment, or complications. 1

Alternative first-line options include second-generation cephalosporins (cefuroxime-axetil) and third-generation cephalosporins (cefpodoxime-proxetil, cefotiam-hexetil, but NOT cefixime). 1, 2

Treatment duration: 7-10 days for sinusitis, with some cephalosporins demonstrating efficacy with 5-day courses. 1

Streptococcal Pharyngitis

Amoxicillin is the first-line treatment for confirmed streptococcal pharyngitis. 1, 2 The American Academy of Pediatrics emphasizes that antibiotics should only be prescribed if rapid antigen test (RAT) or culture results are positive. 5, 3

• Positive RAT confirming Group A Streptococcus (GAS) etiology justifies antibiotics 5
• Negative RAT with low risk factors for acute rheumatic fever does not usually require antibiotic therapy 5
• Treatment duration: 10 days to prevent acute rheumatic fever 5

Acute Otitis Media (AOM)

Antibiotic therapy is recommended for: 5

• Children below 2 years of age with AOM 5
• Children over 2 years with marked symptoms (high fever, intense earache) 5
• Bilateral AOM with otorrhea 3

For children over 2 years without severe symptoms, watchful waiting with reassessment after 48-72 hours of symptomatic therapy is reasonable. 5

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Critical Pitfalls to Avoid

Do NOT Prescribe Antibiotics For:

• Acute bronchitis in healthy adults, even with fever present 1
• Viral rhinosinusitis lasting <10 days unless severe symptoms are present 1, 4
• Common cold, influenza, COVID-19, or laryngitis 4
• Isolated redness of tympanic membrane without other AOM criteria 5

Inappropriate Antibiotic Choices:

• First-generation cephalosporins (cephalexin) lack adequate activity against penicillin-resistant S. pneumoniae and should never be used for respiratory tract infections 1
• Fluoroquinolones inactive on pneumococci (ofloxacin, ciprofloxacin) and cefixime are not recommended 5
• Azithromycin should not be used as first-line therapy due to resistance rates of 20-25% 1

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Reassessment Timeline

Therapeutic efficacy must be assessed after 2-3 days of antibiotic treatment. 1, 2 If no improvement occurs, clinical and radiological reassessment is necessary, and hospitalization should be considered for complications. 1 The primary assessment criterion is fever resolution, which typically occurs within 24 hours for pneumococcal infections and 2-4 days for other bacterial etiologies. 1