What is the recommended management for an uncomplicated upper respiratory infection (URI), including supportive care, medication dosing, red‑flag signs, and indications for antibiotics?

Management of Uncomplicated Upper Respiratory Infection

Primary Recommendation

Do not prescribe antibiotics for uncomplicated viral upper respiratory infections—they provide no clinical benefit, increase adverse events, and drive antimicrobial resistance. 1, 2

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Supportive Care Measures

Symptomatic relief is the cornerstone of URI management:

• Analgesics/Antipyretics: Acetaminophen, ibuprofen, or naproxen for pain, fever, and malaise 3
• Hydration: Ensure adequate fluid intake 2
• Nasal saline irrigation: May provide symptom relief and potentially faster recovery 2
• Cough suppressants: Dextromethorphan or codeine (limited evidence for benefit) 1
• Decongestants: Phenylephrine for nasal congestion 1
• First-generation antihistamines: Diphenhydramine for rhinorrhea 1
• Expectorants: Guaifenesin (limited evidence) 1

Important caveat: Avoid decongestants and antihistamines in children under 3 years due to potential adverse effects 2. Over-the-counter symptomatic therapies have not been shown to shorten illness duration and carry minor adverse effects including nausea, vomiting, headache, and drowsiness 1.

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Expected Clinical Course

Viral URIs follow a predictable pattern:

• Symptoms typically last 5-7 days, peaking around days 3-6 2
• Nasal discharge changes from clear/watery to thick/purulent mid-illness, then returns to clear before resolving 2
• Fever, when present, occurs early and resolves within 24-48 hours 2
• Purulent nasal discharge does not indicate bacterial infection—it reflects inflammatory cells and sloughed epithelial cells, not bacterial pathogens 1, 2

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Red-Flag Signs Requiring Further Evaluation

Instruct patients to return if they develop:

• Persistent symptoms ≥10 days without improvement (suggests acute bacterial rhinosinusitis) 4, 2
• Worsening/biphasic course: Initial improvement followed by worsening symptoms ("double worsening") 4, 2
• Severe onset: High fever (>39°C) with purulent nasal discharge and facial pain for ≥3-4 consecutive days 4, 2
• Persistent high fever >3 days 2
• Signs of respiratory distress 2

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Indications for Antibiotic Therapy

Antibiotics are indicated only when acute bacterial rhinosinusitis is diagnosed based on:

1. Persistent symptoms (≥10 days without improvement)—most common presentation (72% of cases) 4
2. Worsening/biphasic course (improvement then worsening) 4
3. Severe onset (high fever >39°C + purulent discharge + facial pain for ≥3-4 days) 4

When antibiotics are warranted:

• First-line: Amoxicillin with or without clavulanate 4
• Consider amoxicillin-clavulanate if: severe symptoms, recent antibiotic exposure (<6 weeks), or high local prevalence of β-lactamase-producing Haemophilus influenzae 1, 4
• Avoid macrolides and oral third-generation cephalosporins due to high pneumococcal resistance rates 1, 4
• Typical duration: 5-7 days for most URIs 1
• Shorter courses (e.g., 7 vs 10 days) minimize adverse events and resistance development 1

Key bacterial pathogens in secondary infections: Streptococcus pneumoniae (25-30%), Haemophilus influenzae (15-20%), and Moraxella catarrhalis (15-20%) 4

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Common Pitfalls to Avoid

Do not prescribe antibiotics based on:

• Purulent nasal discharge or green/yellow sputum color—these do not distinguish viral from bacterial infection 1, 2, 5
• Duration <10 days—viral URIs commonly last 7-10 days 2
• Patient or family pressure—engage in shared decision-making about observation strategies 1

Do not order imaging studies to distinguish viral URI from bacterial sinusitis 2

Recognize that antibiotic overuse:

• Increases individual and community antimicrobial resistance 2
• Raises risk of Clostridioides difficile colitis, especially in children 2
• Causes more adverse events than placebo (particularly with amoxicillin-clavulanate and macrolides) 1

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Prevention Strategies

• Proper hand hygiene 2
• Cough/sneeze etiquette (covering with elbow or tissue) 2
• Avoiding close contact with sick individuals 2
• Age-appropriate vaccinations 2

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Special Considerations

Observation/"delayed prescribing" strategy: For borderline cases (e.g., symptoms at 7-9 days), consider providing a prescription with instructions to fill only if symptoms persist beyond 10 days or worsen—this approach reduces antibiotic use without compromising outcomes when supported by close follow-up 1, 2. This is particularly appropriate for older children and adults without severe symptoms 1.

Children in daycare: May have more protracted viral symptoms, with up to 13% lasting >15 days 2