What is the management plan for Upper Respiratory Tract Infection (URTI)?

From the Guidelines

For an upper respiratory infection (URI), the medical decision making (MDM) involves assessing the likely viral etiology, evaluating symptom severity, and determining appropriate management, with a focus on supportive care and avoiding unnecessary antibiotic use, as most URIs are viral and self-limiting 1.

Key Considerations

• Most URIs are viral and self-limiting, requiring only supportive care including rest, adequate hydration, and over-the-counter medications for symptom relief.
• Acetaminophen (325-650mg every 4-6 hours, not exceeding 3000mg daily) or ibuprofen (400-600mg every 6-8 hours with food) can help manage fever and pain.
• Saline nasal sprays and humidifiers may alleviate nasal congestion.
• Antihistamines like diphenhydramine (25-50mg every 6 hours) can reduce rhinorrhea, while decongestants such as pseudoephedrine (30-60mg every 4-6 hours) may temporarily relieve nasal stuffiness but should be avoided in patients with hypertension.

Antibiotic Use

• Antibiotics are generally not indicated unless there is strong evidence of bacterial infection such as symptoms persisting beyond 10-14 days, purulent nasal discharge with facial pain, or fever above 102°F lasting more than 3 days 1.
• Patients should be advised to return if symptoms worsen or fail to improve within 7-10 days, as this may indicate secondary bacterial infection or alternative diagnosis requiring different treatment.

Nonpharmacological Interventions

• Mask use and hand hygiene have emerged as the most efficacious strategies to impede viral transmission, with a high level of evidence and a favorable safety profile 1.
• Saline nasal washing and gargling are two low-cost interventions with minimal potential harm, although the available evidence suggests potential benefit, and consideration of the potential risks should be taken into account.

From the FDA Drug Label

2.1 Adults The usual adult dose is one 500 mg/125 mg amoxicillin and clavulanate potassium tablet every 12 hours or one 250 mg/125 mg amoxicillin and clavulanate potassium tablet every 8 hours For more severe infections and infections of the respiratory tract, the dose should be one 875 mg/125 mg amoxicillin and clavulanate potassium tablet every 12 hours or one 500 mg/125 mg amoxicillin and clavulanate potassium tablet every 8 hours.

The recommended dose for an upper respiratory infection is:

• Mild infections: 500 mg/125 mg every 12 hours or 250 mg/125 mg every 8 hours
• More severe infections: 875 mg/125 mg every 12 hours or 500 mg/125 mg every 8 hours 2

Key points to consider:

• The dose and frequency of administration may vary depending on the severity of the infection
• Patients should be advised to take the medication at the start of a meal to minimize gastrointestinal intolerance
• The 250 mg/125 mg and 500 mg/125 mg tablets contain the same amount of clavulanic acid, but two 250 mg/125 mg tablets are not equivalent to one 500 mg/125 mg tablet 2

From the Research

Management of Upper Respiratory Infection

The management of upper respiratory infections (URTI) involves a combination of symptom management and, in some cases, antibiotic therapy.

• The common cold, rhinosinusitis, pharyngitis, and acute otitis media (AOM) are all types of URTIs, with the majority being viral in origin 3.
• For the common cold, recommended therapy involves symptom management with over-the-counter drugs, although the use of these drugs is advised against in children younger than 6 years by the Food and Drug Administration 3.
• Acute rhinosinusitis is typically viral, but a bacterial etiology is more likely if symptoms last longer than 10 days, the temperature is greater than 39°C (102.2°F), or if symptoms worsen after initial improvement 3.
• Antibiotics are not recommended for acute rhinosinusitis unless symptoms worsen or do not improve after an additional 7 days 3.
• Acute pharyngitis is also typically of viral origin, and antibiotics should only be prescribed if test or culture results are positive for streptococcal pharyngitis 3, 4.
• The treatment of choice for streptococcal infection is penicillin V given in two daily doses 4.
• AOM can be managed without antibiotics except in certain high-risk patients, such as children younger than 6 months, children ages 6 to 23 months with bilateral AOM, and children older than 2 years with bilateral AOM and otorrhea 3, 4, 5.
• Amoxicillin is the drug of choice for AOM, given its effectiveness against the predominant causative pathogens, including Streptococcus pneumoniae, Haemophilus influenzae non-type b, and Moraxella catarrhalis 4, 5.
• In cases where amoxicillin therapy fails, amoxicillin/clavulanate provides better coverage against beta-lactamase producing H. influenzae and M. catarrhalis 4.
• Early intervention in the management of URTI can reduce symptom severity and viral transmission, with mucoadhesive gel nasal sprays showing promising results for early intervention 6.

Antibiotic Use

Antibiotic use in URTIs should be judicious and evidence-based to contain costs and prevent adverse effects and drug resistance 7.

• Antibiotics are not recommended for the common cold or laryngitis 7.
• Persistent cases of rhinosinusitis may necessitate the use of antibiotics if symptoms persist beyond a period of observation 7.
• The Infectious Diseases Society of Southern Africa has developed a guideline for the management of URTIs, which includes recommendations for antibiotic use and alternative antibiotic choices 5.

Guideline Recommendations

The guidelines for the management of URTIs recommend the following:

• Penicillin remains the drug of choice for tonsillopharyngitis, with single-dose parenteral administration of benzathine penicillin being effective, but many favour oral administration twice daily for 10 days 5.
• Amoxycillin remains the drug of choice for both AOM and acute bacterial sinusitis (ABS), with a dose of 90 mg/kg/day recommended in general 5.
• Alternative antibiotic choices are given in the guideline, with recommendations for their specific indications, including amoxycillin-clavulanate, some cephalosporins, the macrolide/azalide and ketolide groups of agents, and the respiratory fluoroquinolones 5.