Management of Acute Upper Respiratory Tract Infection in Healthy Adults
For an otherwise healthy adult with an acute upper respiratory tract infection, antibiotics should NOT be prescribed, as over 90% of these infections are viral and self-limiting; management should focus on symptomatic treatment with reassurance and specific criteria-based follow-up. 1
Initial Assessment and Diagnosis
Distinguish between viral URTI and conditions requiring antibiotics:
- URTIs are predominantly viral (>90% of cases) and occur above the vocal cords with normal pulmonary auscultation 1, 2
- Fever and cough of only 2 days duration does NOT warrant antibiotics, even if fever is present 1
- Pneumonia is unlikely in the absence of ALL of the following: tachycardia (>100 bpm), tachypnea (>24 breaths/min), fever >38°C for more than 3 days, and abnormal chest examination findings 1
Symptomatic Treatment (First-Line Management)
Provide supportive care for symptom relief:
- Analgesics and antipyretics for pain and fever relief 1, 2
- Intranasal saline irrigation for nasal congestion 1, 2
- Intranasal corticosteroids for symptom relief 1, 2
- Systemic or topical decongestants as needed 2
- Cough suppressants (dextromethorphan or codeine) may be prescribed for dry, bothersome cough 3
Avoid ineffective treatments:
- Do NOT prescribe expectorants, mucolytics, antihistamines, inhaled corticosteroids, or bronchodilators for acute URTI 3
When to Consider Antibiotics (Specific Criteria Only)
Antibiotics are indicated ONLY in these specific situations:
1. Acute Bacterial Rhinosinusitis (ABRS)
Reserve antibiotics for patients meeting ONE of these three criteria: 3, 1
- Persistent symptoms >10 days without improvement 3, 1, 2
- Severe symptoms for ≥3 consecutive days: high fever (>39°C) with purulent nasal discharge or facial pain 3, 1, 2
- "Double sickening": worsening symptoms after initial improvement following a typical 5-day viral illness 3, 1, 2
First-line antibiotic: Amoxicillin-clavulanate 1, 2 Alternatives: Doxycycline or respiratory fluoroquinolones (levofloxacin, moxifloxacin) 2
2. Group A Streptococcal Pharyngitis
Confirm diagnosis before treating: 3, 1
- Test with rapid antigen detection test (RADT) and/or throat culture before prescribing antibiotics 3, 1
- First-line antibiotic: Amoxicillin for 10 days 1, 2
- Do NOT prescribe antibiotics for viral pharyngitis 3, 4
3. Acute Otitis Media (in adults, less common)
Diagnose only with all three criteria: abrupt onset, signs of middle ear effusion, and symptoms of middle ear inflammation 1
Critical Follow-Up Algorithm
Provide clear return precautions and reassessment timing:
- Reassess in 2-3 days if symptoms are severe or patient has risk factors 1
- Consider antibiotics only if fever (>38°C) persists beyond 3 days 1
- Advise patient to return if symptoms persist >3 weeks 3
- Instruct patient to contact immediately if: fever exceeds 4 days, dyspnea worsens, patient stops drinking, or consciousness decreases 3
Common Pitfalls to Avoid
Critical errors that lead to inappropriate antibiotic use:
- Purulent or colored (green/yellow) sputum does NOT indicate bacterial infection and should NOT trigger antibiotic prescription 1, 4
- Presence of fever alone does NOT warrant antibiotics in the first 2-3 days 1
- Patient pressure or expectation should not override evidence-based criteria 3, 4
- The number needed to harm (8) exceeds the number needed to treat (18) for acute rhinosinusitis, highlighting risks of inappropriate use 1
Patient Education Points
Explain to patients:
- Viral infections typically last 7-14 days and resolve without antibiotics 1
- Antibiotics cause side effects (diarrhea, rash, potentially life-threatening reactions) and contribute to resistance 3, 1
- Symptomatic treatment is effective for managing discomfort while the infection resolves 1, 2