Management of Upper Respiratory Tract Infections
Most upper respiratory tract infections are viral and self-limited, requiring only symptomatic treatment with analgesics and nasal saline—antibiotics should be avoided as they provide no benefit and cause harm. 1
Key Diagnostic Principle
Do not prescribe antibiotics for viral URIs. The vast majority of URIs (common cold, viral pharyngitis, acute bronchitis, laryngitis) are caused by viruses and resolve spontaneously within 10-14 days. 1, 2 Discolored nasal discharge alone does not indicate bacterial infection—it simply reflects inflammation and is not specific for bacterial involvement. 1
Recommended Symptomatic Management
First-Line Treatments
- Analgesics/antipyretics (acetaminophen or ibuprofen) for pain or fever relief 1
- Nasal saline irrigation provides cleansing and palliative effects with minimal adverse reactions 1
- Oral decongestants may relieve congestion, but avoid in patients with hypertension or anxiety 1
Treatment Duration
- Continue symptomatic treatments as needed until symptoms resolve, typically within 10-14 days 1
- Most viral URIs peak within 3 days and resolve without specific treatment 1
When to Consider Bacterial Infection
Suspect bacterial sinusitis only when:
- Symptoms persist >10 days without clinical improvement 1
- Severe symptoms present: fever >39°C (102.2°F), purulent nasal discharge, or facial pain lasting >3 consecutive days 1
- Symptoms worsen after initial improvement (double-worsening) 1
Critical Antibiotic Stewardship Points
The number needed to harm from antibiotic adverse effects (8) is lower than the number needed to treat for benefit (18) in acute rhinosinusitis. 1 This means you are more likely to harm than help by prescribing antibiotics inappropriately.
Why Antibiotics Are Harmful in Viral URIs
- Over 80% of ambulatory sinusitis visits result in unnecessary antibiotic prescriptions 1
- Excessive antibiotic use drives bacterial drug resistance 1
- Antibiotics are ineffective against viral pathogens and contribute to antimicrobial resistance 1, 2
When Antibiotics ARE Indicated
Do NOT use antibiotics for:
Antibiotics ARE appropriate for:
- Acute otitis media (in specific populations) 2, 4
- Group A beta-hemolytic streptococcal pharyngitis (culture/test confirmed) 2, 4
- Epiglottitis 2
- Bacterial sinusitis meeting criteria above 1
Special Populations
Pediatric Patients
- Use similar symptomatic management with careful attention to appropriate medication dosing 1
- FDA advises against over-the-counter cold medications in children <6 years 4
- For bacterial infections requiring treatment, use weight-based dosing of amoxicillin 5
Patients with Chronic Respiratory Conditions
Common Pitfalls to Avoid
- Do not prescribe antibiotics to prevent bacterial superinfection—treatment of URIs with antibiotics will not prevent lower respiratory tract infections 3
- Do not interpret fever alone as indication for antibiotics—fever is common in viral infections and does not distinguish viral from bacterial etiology 3
- Do not use antibiotics for patient satisfaction—focus on education about self-limited nature and symptomatic management 1, 2