Treatment of Upper Respiratory Tract Infections
Primary Recommendation
Most upper respiratory tract infections (URTIs) are viral and should be managed with symptomatic treatment only—antibiotics are not indicated and do not hasten recovery or prevent serious illness. 1, 2
Symptomatic Management (First-Line for All URTIs)
The cornerstone of URTI treatment is supportive care, which should be offered to all patients:
- Analgesics (acetaminophen, NSAIDs) for pain relief 2
- Antipyretics for fever control 2
- Nasal saline irrigation for nasal congestion 2
- Intranasal corticosteroids for symptom relief 2
- Systemic or topical decongestants as needed 2
Important caveat: The FDA advises against over-the-counter cold medications in children younger than 6 years 3
When Antibiotics Are NOT Indicated
Antibiotics should be avoided in the following common scenarios:
- Common cold/nonspecific URTI: Always viral, self-limiting 1, 2
- Acute bronchitis in healthy adults: Even with fever or purulent sputum, antibiotics are not indicated 2
- Acute rhinosinusitis lasting less than 10 days: Typically self-limited even when bacterial 1, 3
- Viral pharyngitis: Only treat if streptococcal testing is positive 2
Critical point: Treatment of URTIs with antibiotics will not prevent progression to lower respiratory tract infections 4
Specific Situations Requiring Antibiotics
Acute Bacterial Rhinosinusitis
Antibiotics should be considered only when:
- Symptoms persist >10 days without improvement, OR
- Severe symptoms (fever >39°C/102.2°F, facial pain) for ≥3 consecutive days, OR
- Symptoms worsen after initial improvement ("double worsening") 1, 3
First-line antibiotic: Amoxicillin-clavulanate 875/125 mg every 12 hours for 7-10 days 1, 2
Alternatives: Cefuroxime-axetil or cefpodoxime-proxetil (avoid cefixime) 2
Streptococcal Pharyngitis
Acute Otitis Media
Children <6 months: Always treat with antibiotics 2, 3
Children 6-23 months: Treat if bilateral AOM 3
Children >2 years: Treat only if bilateral AOM with otorrhea or marked symptoms (high fever, intense earache) 1, 3
First-line: Amoxicillin-clavulanate 80-100 mg/kg/day (amoxicillin component) in 3 divided doses for children <3 years 1
Duration: 8-10 days for children <2 years; 5 days for older children 2
High-Risk Patients Requiring Different Approach
Consider immediate antibiotics or hospital referral for patients with:
- Systemic illness with features of serious complications 5
- Age >65 years with acute cough PLUS ≥2 of: recent hospitalization, diabetes, heart failure, oral corticosteroid use 5
- Age >80 years with acute cough PLUS ≥1 of the above risk factors 5
- Pre-existing comorbidities (cardiac, pulmonary, renal disease, diabetes) 4, 5
Monitoring and Follow-Up
Assess treatment efficacy within 2-3 days:
- Symptoms should improve within 48-72 hours of effective antibiotic therapy 2
- If no improvement, clinical reassessment is necessary—do not change antibiotics before 72 hours unless worsening 4, 2
Instruct patients to return if:
- Fever persists >4 days 4
- Dyspnea worsens 4
- Patient stops drinking 4
- Consciousness decreases 4
- Symptoms take >3 weeks to resolve 4
Critical Pitfalls to Avoid
Discolored nasal discharge does NOT indicate bacterial infection: This is a common misconception—purulent discharge occurs with viral URTIs and does not justify antibiotics 2, 6
Amoxicillin-clavulanate has higher adverse event rates (particularly gastrointestinal) compared to amoxicillin alone—reserve for appropriate indications only 1
Inappropriate antibiotic use drives resistance: The majority of URTIs are viral, yet they remain the most common reason for antibiotic prescriptions in adults 3, 7
Consider delayed prescribing strategy: For borderline cases, provide a prescription with instructions to fill only if symptoms worsen or fail to improve after 7 days 1, 5