What is the recommended management for upper respiratory tract infections, including supportive care, appropriate medication dosing, and indications for antibiotics?

Management of Upper Respiratory Tract Infections

Most upper respiratory tract infections are viral and do not require antibiotics; supportive care alone is appropriate for the common cold, acute bronchitis, and most cases of pharyngitis and rhinosinusitis. 1

Immediate Decision: Does This Patient Need Antibiotics?

Do NOT prescribe antibiotics for:

• Acute bronchitis – Over 90% are viral; antibiotics show no benefit and increase adverse events 1
• Common cold/viral rhinitis – Always viral; antibiotics are ineffective 1, 2
• Most pharyngitis – Only 10% of adult cases and 15-30% of pediatric cases are bacterial (Group A Streptococcus) 1
• Acute rhinosinusitis lasting less than 7 days – Watchful waiting is appropriate; 86% improve with placebo within 7-15 days 3

Consider antibiotics ONLY when:

• Pharyngitis with high probability of Group A Streptococcus (use clinical scoring systems to assess likelihood) 1
• Acute bacterial rhinosinusitis with symptoms persisting beyond 7 days OR worsening at any time 3
• Pneumonia is suspected based on focal chest findings, tachycardia >100 bpm, tachypnea >24 breaths/min, fever >38°C, and abnormal lung examination 1

Supportive Care (First-Line for All URTIs)

Symptomatic relief options include:

• Analgesics/antipyretics: Acetaminophen or ibuprofen for pain and fever 4
• Decongestants: Phenylephrine for nasal congestion 1
• Antihistamines: First-generation agents (diphenhydramine) may help with rhinorrhea 1
• Cough suppressants: Dextromethorphan or codeine, though evidence for benefit is limited 1
• Expectorants: Guaifenesin for productive cough 1

Important caveat: β-agonists (albuterol) do NOT benefit patients without underlying asthma or COPD 1. Over-the-counter therapies carry low risk of minor adverse effects (nausea, drowsiness) but do not shorten illness duration 1.

When Antibiotics Are Indicated: Specific Regimens

Acute Bacterial Rhinosinusitis (ABRS)

• First-line: Amoxicillin 500-1000 mg every 8 hours for 5-10 days 3, 5
• Use amoxicillin-clavulanate instead if β-lactamase-producing organisms suspected (chronic lung disease, recent antibiotic use) 3
• Penicillin allergy: Macrolide (clarithromycin) or doxycycline 3
• Treatment failure at day 7: Re-evaluate diagnosis and switch to alternative agent 3

Group A Streptococcal Pharyngitis

The guidelines reviewed focus primarily on diagnosis rather than specific treatment regimens, but amoxicillin remains the reference standard for confirmed bacterial pharyngitis 1. Dosing has been increased to 500-1000 mg every 8 hours due to rising penicillin resistance 1.

Community-Acquired Pneumonia (Outpatient)

• First-line for patients without risk factors: Amoxicillin 500-1000 mg every 8 hours for 5-7 days 3, 6
• Patients with risk factors (age >65, recent antibiotics, chronic lung disease, recent hospitalization): Amoxicillin-clavulanate 3, 6
• Penicillin allergy: Macrolide (azithromycin) or doxycycline 3, 7
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) reserved for treatment failures only 3, 7

Critical pitfall: Do NOT use cefuroxime as automatic first-line in patients with chronic lung disease or recent antibiotic exposure; amoxicillin-clavulanate provides superior coverage of β-lactamase-producing organisms 6.

Dosing Adjustments

Amoxicillin dosing has been doubled from historical recommendations:

• Current standard: 500-1000 mg every 8 hours (1.5-3 g/day total) 1, 5
• Rationale: Rising prevalence of penicillin-resistant Streptococcus pneumoniae (35% in some regions) 1
• Renal impairment: Reduce dose if GFR <30 mL/min 5

Pediatric dosing:

• Children >3 months: 20-45 mg/kg/day divided every 8-12 hours 5
• Neonates and infants ≤3 months: Maximum 30 mg/kg/day divided every 12 hours 5

Red Flags Requiring Immediate Referral or Further Evaluation

Refer to hospital if any of the following:

• Respiratory rate ≥30 breaths/min 3, 7
• Temperature <35°C or ≥40°C 3, 7
• Heart rate ≥125 beats/min 3, 7
• Blood pressure <90/60 mmHg 3, 7
• Cyanosis, altered mental status, or confusion 3, 7
• Suspected complications (pleural effusion, cavitation) 7

Follow-Up and Patient Counseling

Set clear expectations:

• Reassess if fever persists beyond 48 hours after starting antibiotics 3, 7
• Cough may persist for weeks after antibiotic completion and does NOT indicate treatment failure 6, 7
• Most viral URTIs resolve in 7-10 days without antibiotics 1, 3

Delayed prescribing strategy:

For borderline cases (e.g., rhinosinusitis at day 5-7), provide a prescription with instructions to fill only if symptoms worsen or fail to improve within 48-72 hours 8. This reduces unnecessary antibiotic use while providing safety net for patients 8.

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics for purulent sputum color alone – green or yellow sputum reflects inflammatory cells, not bacterial infection 1
• Do NOT use macrolides (azithromycin) routinely for acute bronchitis – they cause more adverse events than placebo without benefit 1
• Do NOT use throat culture results to guide initial antibiotic decisions – results take 2-3 days and cannot distinguish acute infection from carrier state 1
• Do NOT assume all patients with COPD exacerbation need antibiotics – only prescribe when increased sputum purulence is present 1, 7