Treatment for Upper Respiratory Infection
Uncomplicated upper respiratory tract infections (URIs) are viral in over 90% of cases and do NOT require antibiotics—treatment focuses on symptom relief with analgesics, decongestants, and supportive care. 1, 2
Confirm the Diagnosis: URI vs. Bacterial Complications
Before treating, distinguish between viral URI and conditions requiring antibiotics:
- Viral URI (common cold) presents with nasal congestion, rhinorrhea, sore throat, cough, and low-grade fever, with symptoms typically peaking at days 3-6 and resolving within 5-7 days (though cough may persist up to 3 weeks). 1, 2
- Most URIs resolve spontaneously within 1-2 weeks without any intervention. 2
- Purulent nasal discharge does NOT indicate bacterial infection—this reflects neutrophil activity in viral inflammation and does not predict antibiotic benefit. 2
Do NOT prescribe antibiotics for uncomplicated URI—multiple randomized controlled trials demonstrate no reduction in symptom duration or severity, and inappropriate use drives antibiotic resistance. 1
Evidence-Based Symptomatic Treatment
Pain and Fever Management
- Acetaminophen or ibuprofen for sore throat, headache, chest discomfort, and fever. 1, 3
- Throat lozenges for sore throat relief. 1
Nasal Congestion
- Pseudoephedrine (oral decongestant) if nasal congestion is bothersome. 1
- Antihistamines alone are NOT effective for URI symptoms and should not be used as monotherapy. 1
Persistent Cough (Beyond 3-5 Days)
- Inhaled ipratropium bromide is the ONLY recommended first-line cough suppressant if cough persists beyond 3-5 days and is bothersome (Grade A recommendation). 1
- Do NOT prescribe benzonatate or other peripheral/central cough suppressants—they have limited efficacy in acute viral infections. 1
Supportive Measures
- Adequate hydration and rest are essential for recovery. 1
Expected Clinical Course and Red Flags
- Symptoms typically peak at days 3-6 and should begin improving thereafter. 1
- Most uncomplicated viral URIs resolve within 5-7 days, though cough may persist for up to 3 weeks (post-infectious cough). 1
- Transient bronchial hyperresponsiveness can last 2-3 weeks, occasionally up to 2 months. 1
When to Reassess for Bacterial Complications
Return immediately if:
- Symptoms persist >10 days without improvement—suggests possible bacterial sinusitis. 1, 2
- Symptoms worsen after initial improvement ("double sickening")—suggests bacterial superinfection. 1, 2
- Fever >39°C (102.2°F) with purulent discharge for ≥3 consecutive days—suggests bacterial sinusitis. 4
- Development of focal chest findings or significant dyspnea—requires reconsideration of pneumonia. 1
- New severe symptoms develop (severe headache, visual changes, periorbital swelling, altered mental status)—suggests complications requiring urgent evaluation. 5
Common Pitfalls to Avoid
- Do NOT prescribe antibiotics based on purulent nasal discharge or sputum color—these do NOT predict bacterial infection. 2
- Do NOT prescribe antibiotics for cough lasting <3 weeks—prolonged cough alone is NOT an indication for antibiotics in uncomplicated URI. 1
- Do NOT obtain routine imaging (X-ray or CT) for uncomplicated URI—reserve imaging only for suspected complications. 1
- Approximately 70% of adults presenting with acute cough have viral URI—this is the most likely diagnosis in the absence of abnormal vital signs or focal chest findings. 1
Special Consideration: Distinguishing URI from Bacterial Sinusitis
- Viral rhinosinusitis (congestive rhinosinusitis) accompanying or following viral URI resolves within 21 days without antibiotics and does NOT require treatment. 2
- Acute bacterial sinusitis follows only 0.5-13% of viral URIs and requires specific diagnostic criteria (persistent symptoms ≥10 days, severe symptoms ≥3-4 days, or "double sickening"). 2, 5
- Up to 90% of viral URIs show CT evidence of sinus involvement, yet these resolve without antibiotics—imaging findings alone do NOT indicate bacterial infection. 2