Treatment of Upper Respiratory Infection (URI) Symptoms
For uncomplicated URI symptoms, symptomatic management without antibiotics is the recommended approach, as most URIs are viral and self-limited. 1, 2
Distinguishing Viral URI from Bacterial Rhinosinusitis
The critical first step is determining whether the patient has a simple viral URI or acute bacterial rhinosinusitis (ABRS), as this determines whether antibiotics are indicated. 1
Diagnose ABRS (requiring antibiotics) only if ANY of the following three presentations occur: 1
- Persistent symptoms lasting ≥10 days without improvement (nasal drainage, congestion, facial pressure/pain, postnasal drainage, cough) 1
- Severe symptoms at onset: high fever ≥39°C (102°F) with purulent nasal discharge or facial pain for at least 3-4 consecutive days 1
- "Double-sickening": worsening symptoms after initial improvement, with new onset of fever, headache, or increased nasal discharge following a typical viral URI that lasted 5-6 days 1
If none of these three criteria are met, treat as viral URI with symptomatic management only—antibiotics are not indicated. 1
Symptomatic Management for Viral URI
First-Line Treatment for Persistent Cough
Inhaled ipratropium bromide is the only recommended first-line treatment for persistent post-URI cough (Grade A recommendation). 3 This anticholinergic agent suppresses cough through airway effects with minimal systemic absorption (only 7% absorbed systemically). 3
What NOT to Use
Do not prescribe systemic corticosteroids for uncomplicated URI or acute bronchitis—they provide no benefit and are not justified. 4 Corticosteroids do not prevent bacterial superinfection or improve clinical outcomes in viral respiratory infections. 4
Avoid central cough suppressants (codeine, dextromethorphan) for URI-related cough due to limited efficacy (Grade D recommendation). 3, 5 Multiple studies show these agents are no more effective than placebo. 5
Do not use over-the-counter combination cold medications until randomized controlled trials prove effectiveness. 3
Adjunctive Symptomatic Therapies
For nasal congestion, use isotonic saline nasal irrigation rather than hypertonic solutions, which cause side effects. 6 Hypertonic saline is specifically not recommended. 6
Intranasal corticosteroids may be offered for symptom reduction in post-viral acute rhinosinusitis if needed. 6 However, there is no evidence supporting intranasal corticosteroids for symptomatic relief of the common cold itself. 6
Guaifenesin may help as an expectorant by increasing mucus volume and thinning secretions, potentially decreasing subjective cough measures. 3
For pain or fever, use acetaminophen, ibuprofen, or naproxen; for congestion and runny nose, antihistamines and/or decongestants may provide symptomatic relief. 2
Antibiotic Treatment (Only for Confirmed ABRS)
If ABRS is diagnosed based on the three criteria above, antibiotics are indicated. 1
First-Line Antibiotic Selection
Use first-line therapy based on local antibiogram: amoxicillin (for β-lactamase-negative organisms), nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin. 1, 7
Amoxicillin is indicated for upper respiratory tract infections of the ear, nose, and throat due to susceptible (ONLY β-lactamase-negative) isolates of Streptococcus species, Streptococcus pneumoniae, Staphylococcus spp., or Haemophilus influenzae. 7
Antibiotic Duration and Stewardship
Treat with as short a duration as reasonable, generally no longer than 5-7 days for uncomplicated cases. 1 This approach reduces antimicrobial resistance while maintaining efficacy. 1
Assess for risk factors requiring second-line therapy before prescribing: 1
- Age <2 or >65 years
- Daycare attendance
- Prior antibiotics within past month
- Prior hospitalization in past 5 days
- Comorbidities or immunocompromised status
If risk factors are present, initiate second-line antimicrobial therapy and complete 7-10 days of treatment. 1
Critical Clinical Pitfalls
Do not confuse acute viral bronchitis with asthma exacerbations or COPD, which may benefit from corticosteroids—these conditions must be ruled out before diagnosing simple acute bronchitis. 4
Purulent sputum during acute bronchitis does NOT indicate bacterial superinfection requiring antibiotics in healthy adults. 4
Fever persisting more than 7 days suggests bacterial superinfection or pneumonia, requiring reassessment rather than empiric therapy. 4
If using decongestants, monitor blood pressure as they can worsen hypertension and cause tachycardia. 6
A change in nasal discharge color is NOT a specific sign of bacterial infection and should not trigger antibiotic prescription. 1
Monitoring and Follow-Up
Reassess patients after 3-5 days of antibiotic therapy for ABRS. 1 If worsening or no improvement occurs, broaden coverage or switch to a different antimicrobial class. 1
If symptoms worsen or fail to improve after appropriate antibiotic therapy, refer to a specialist and consider CT or MRI to investigate noninfectious causes or suppurative complications. 1