What is the recommended treatment approach for Upper Respiratory Tract Infections (URTI) in adults and children?

Treatment of Upper Respiratory Tract Infections (URTI)

Antibiotics should NOT be used for uncomplicated viral URTIs in adults or children, as they provide no benefit, do not prevent complications, and contribute to antibiotic resistance. 1, 2, 3

Initial Management: Symptomatic Treatment Only

Most URTIs are viral and self-limited, resolving within 7-10 days without specific treatment. 1, 2

Recommended Symptomatic Therapies:

• Analgesics/antipyretics (acetaminophen or ibuprofen) for pain, fever, and inflammation 2, 3, 4

• Adequate hydration and rest as supportive measures 2, 3

• Nasal saline irrigation may provide minor symptomatic improvement 2, 3

• Oral decongestants if no contraindications exist 2, 3

• Topical decongestants for no more than 3-5 days to avoid rebound congestion 2

• Dextromethorphan or codeine for dry, bothersome cough 2

• Expectorants (guaifenesin) may be used, though clinical efficacy evidence is limited 2

Critical Point: Discolored Nasal Discharge Does NOT Indicate Bacterial Infection

Purulent or discolored nasal discharge is a sign of inflammation, not bacterial infection, and does not justify antibiotic use. 2, 3, 4

When to Consider Bacterial Infection and Antibiotics

Antibiotics should ONLY be prescribed when specific clinical criteria for bacterial infection are met:

Criteria for Bacterial Rhinosinusitis:

• Persistent symptoms for more than 10 days without clinical improvement 3, 4

• Severe symptoms with high fever (>39°C/102.2°F) AND purulent nasal discharge lasting at least 3 consecutive days 3

• Worsening course: symptoms that initially improved but then worsen (double-worsening pattern) 3, 4

Antibiotic Selection When Bacterial Infection is Confirmed:

• First-line: Amoxicillin 750-1750 mg/day in divided doses every 8-12 hours for adults 3, 5

• For pediatric patients >3 months: 20-45 mg/kg/day in divided doses every 8-12 hours 5

• Amoxicillin-clavulanate is recommended for patients with antibiotic use in the previous 30 days, concurrent purulent conjunctivitis, or when β-lactamase-producing organisms are suspected 3, 4

• For penicillin allergy (non-type I): Cephalosporins such as cefdinir, cefuroxime, or cefpodoxime 3

Follow-Up and Red Flags

Patients Should Return If:

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

Reassess if no improvement within 48-72 hours of antibiotic initiation 3

Prevention Strategies

• Influenza vaccination can reduce influenza-associated URTIs 2

• Hand hygiene and avoiding close contact with infected individuals 2

• Nasal washing with saline may have prophylactic benefits 2

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics for viral URTIs - they are ineffective and increase antibiotic resistance 1, 2, 3

• Do NOT order imaging studies (CT, X-ray) to distinguish bacterial from viral infection - they do not contribute to diagnosis and increase costs 3, 4

• Do NOT assume purulent discharge equals bacterial infection - this is inflammation, not infection 2, 3, 4

• Do NOT use antibiotics to prevent lower respiratory tract infections - treatment of URTIs with antibiotics does not prevent progression to pneumonia 1

Special Considerations

• Antiviral treatment should only be considered in high-risk patients with typical influenza symptoms present for <2 days during a known influenza epidemic 2

• Topical intranasal steroids may have a role in viral rhinosinusitis management, though not FDA-approved for this indication 2

• Immunocompromised patients require different management approaches and are not covered by standard URTI guidelines 1