What is the initial management for a patient with an Upper Respiratory Tract Infection (URTI), particularly those with a history of asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Initial Management of Upper Respiratory Tract Infection (URTI)

For uncomplicated URTI in patients with asthma or COPD, provide symptomatic treatment only and avoid antibiotics unless specific criteria for bacterial superinfection or true COPD exacerbation are met. 1

Immediate Assessment: Rule Out Conditions Requiring Antibiotics

Exclude Pneumonia First

• Suspect pneumonia if any of the following are present: new focal chest signs on auscultation, dyspnea or tachypnea, pulse >100 bpm, or fever persisting >4 days 1, 2
• Obtain chest radiograph when pneumonia is suspected to confirm diagnosis 1, 3
• If pneumonia is confirmed, initiate antibiotics immediately (amoxicillin or tetracycline as first-line) 1

Differentiate URTI from COPD/Asthma Exacerbation

This distinction is critical because up to 45% of patients with acute cough >2 weeks actually have underlying asthma or COPD rather than simple URTI. 1

Consider lung function testing when ≥2 of the following are present: 1, 2

• Wheezing on examination
• Prolonged expiration
• Smoking history
• History of allergy
• Female sex

Management Based on Diagnosis

For True Viral URTI (No Lower Respiratory Involvement)

Symptomatic treatment only—do NOT prescribe antibiotics, cough suppressants, expectorants, mucolytics, antihistamines, inhaled corticosteroids, or bronchodilators. 1

Appropriate symptomatic measures include: 1, 4

• Analgesics (acetaminophen, ibuprofen, naproxen) for pain or fever
• Reassurance that symptoms typically resolve within 1-2 weeks
• Saline nasal irrigation for congestion

For COPD Patients with URTI Symptoms

Antibiotics are indicated ONLY if true COPD exacerbation criteria are met—specifically, all three Anthonisen criteria: increased dyspnea, increased sputum volume, AND increased sputum purulence. 1, 5

Additional antibiotic indications in COPD patients: 5

• Severe COPD with any two of the three Anthonisen criteria
• Fever >38°C persisting beyond 3 days from symptom onset (suggests bacterial superinfection)

Common pitfall: Purulent nasal discharge alone does NOT indicate bacterial infection and does NOT justify antibiotics in otherwise uncomplicated URTI. 1, 5

If antibiotics are warranted, use amoxicillin-clavulanate 875mg twice daily for 5-7 days as first-line for COPD exacerbations. 5

For Asthma Patients with URTI Symptoms

• Viral URTIs can trigger asthma exacerbations 1
• β-agonists and steroids are beneficial for asthma exacerbations triggered by viral infections 1
• Do NOT use antibiotics unless bacterial superinfection develops (fever >38°C persisting >3 days) 5

High-Risk Patients Requiring Close Monitoring

Consider antibiotics and closer follow-up for patients with: 1

• Age >75 years with fever
• Cardiac failure
• Insulin-dependent diabetes mellitus
• Serious neurological disorder (stroke, etc.)

For patients >65 years, additional risk factors include: 1, 2

• Previous hospitalization in past year
• Oral glucocorticoid use
• Confusion or diminished consciousness
• Pulse >100, temperature >38°C, respiratory rate >30, blood pressure <90/60

Monitoring and Follow-Up

Instruct patients to return if: 1

• Symptoms persist >3 weeks
• Fever persists >4 days
• Dyspnea worsens
• New focal chest signs develop
• Consciousness decreases

If antibiotics are prescribed, clinical improvement should be expected within 3 days. 1

Key caveat: Treatment of URTI with antibiotics will NOT prevent progression to lower respiratory tract infection. 1 The vast majority of URTIs are viral and self-limited, resolving within 1-2 weeks without intervention. 1, 4