Treatment of Upper Respiratory Infection
For uncomplicated upper respiratory infections (URIs), antibiotics are NOT recommended regardless of underlying asthma or COPD, as most URIs are viral and should be managed with symptomatic treatment only. 1, 2
Symptomatic Management for Uncomplicated URI
- Use acetaminophen or aspirin 500-1000 mg for fever and systemic symptoms (headache, achiness, feverish discomfort), which provide significant temperature reduction within 2-4 hours. 3
- Add antihistamines and/or decongestants for nasal congestion and rhinorrhea as needed for symptom relief. 4
- Continue symptomatic treatment for the typical 7-10 day viral course, advising patients that symptoms may persist up to 3 weeks. 5
Critical Decision Point: When Antibiotics ARE Indicated
For Patients with COPD Exacerbation
Antibiotics should ONLY be prescribed when the patient meets specific exacerbation criteria, NOT simply for URI symptoms. 5
Anthonisen Type I Criteria (All 3 Must Be Present):
- Increased dyspnea beyond baseline 5
- Increased sputum volume 5
- Increased sputum purulence (yellow or green) 5
If all three cardinal symptoms are present, initiate antibiotics immediately. 6, 5
For Severe COPD (FEV₁ <35% or chronic respiratory insufficiency):
- Prescribe antibiotics even with fewer than 3 cardinal symptoms if any exacerbation is suspected. 6
- These patients have chronic hypoxemia at rest (PaO₂ <60 mmHg) and are at higher risk for bacterial infection. 6
For Patients with Asthma
- Do NOT prescribe antibiotics for URI symptoms in asthma patients unless pneumonia is confirmed. 1, 2
- Optimize bronchodilator therapy instead: short-acting β₂-agonists (salbutamol 200-400 mcg or terbutaline 500-1000 mcg every 4 hours) for acute symptoms. 6
Distinguishing Pneumonia from Simple URI
Suspect pneumonia when acute cough PLUS one or more of the following are present: 5
- New focal chest signs on examination 5
- Dyspnea (new or worsening) 5
- Tachypnea 5
- Fever lasting >4 days 5
Obtain chest radiograph to confirm pneumonia before starting antibiotics. 5
Antibiotic Selection When Indicated
First-Line Choices for COPD Exacerbation:
For mild-moderate exacerbations (FEV₁ >35%, <4 exacerbations/year):
- Amoxicillin 500-1000 mg three times daily for 5-7 days (preferred first-line). 6, 5, 7
- Doxycycline 100 mg twice daily for 5-7 days (alternative). 5
For moderate-severe exacerbations requiring hospitalization:
- Amoxicillin-clavulanate (co-amoxiclav) for broader coverage including β-lactamase producing organisms. 6
For Penicillin Allergy:
If true Type I hypersensitivity (anaphylaxis):
- Levofloxacin 750 mg once daily for 7-10 days (first choice). 8
- Moxifloxacin 400 mg once daily for 7-10 days (alternative). 8
- Macrolides (azithromycin, clarithromycin) only in regions with low pneumococcal resistance. 5
Pseudomonas Risk Assessment:
Use ciprofloxacin 500-750 mg twice daily if ≥2 of the following are present: 6, 8
- Recent hospitalization (within 3 months) 6
- Frequent antibiotic courses (>4 per year) 6
- Severe COPD (FEV₁ <30%) 6
- Previous Pseudomonas isolation 6
Treatment Duration and Monitoring
- Limit antibiotic treatment to 5-7 days for uncomplicated exacerbations. 5
- Instruct patients to contact physician if no improvement within 3 days of starting antibiotics. 5
- Reassess if symptoms persist >3 weeks, fever exceeds 4 days, or dyspnea worsens. 5
Common Pitfalls to Avoid
- Never prescribe antibiotics for simple URI symptoms without meeting COPD exacerbation criteria - this contributes to antibiotic resistance and provides no benefit. 6, 5, 2
- Do not use prophylactic antibiotics routinely in COPD or asthma - reserve only for patients with >3 exacerbations requiring steroids per year. 6, 5
- Avoid beta-blockers in all COPD patients regardless of other medications, as they can precipitate bronchospasm. 9
- Do not assume fever indicates bacterial infection - fever is common with viral URIs and typically resolves within 3-4 days without antibiotics. 6, 1