Management of Acute Viral Upper Respiratory Tract Infection in Healthy Adults
Do not prescribe antibiotics for uncomplicated viral upper respiratory tract infections in otherwise healthy adults—they provide no clinical benefit and cause harm. 1
Initial Assessment and Diagnosis
Recognize that 80–90% of acute URIs are viral in origin and self-limited. 2, 3 The key clinical task is distinguishing uncomplicated viral URI from conditions requiring antibiotics:
Rule Out Pneumonia
Pneumonia is unlikely in healthy immunocompetent adults under 70 years when all of the following are absent: 1
- Tachycardia (heart rate >100 beats/min)
- Tachypnea (respiratory rate >24 breaths/min)
- Fever (oral temperature >38°C)
- Abnormal chest examination findings (rales, egophony, tactile fremitus)
If pneumonia is suspected based on these criteria, obtain a chest radiograph for confirmation. 1
Distinguish Viral URI from Bacterial Complications
Purulent nasal discharge or sputum color (green or yellow) does NOT indicate bacterial infection and should not trigger antibiotic therapy. 1, 3, 4
Symptomatic Management (First-Line Therapy)
Analgesics and Antipyretics
Use acetaminophen or NSAIDs (ibuprofen, naproxen) for headache, body aches, and fever. 2, 5
Nasal Congestion
Recommend intranasal saline irrigation as first-line therapy for nasal congestion and rhinorrhea. 2
For short-term relief, consider systemic decongestants (pseudoephedrine) or topical decongestants (oxymetazoline), but limit topical agents to ≤3 days to prevent rebound congestion. 2
Prescribe intranasal corticosteroids for persistent nasal symptoms with notable mucosal inflammation. 2
Cough
Prescribe cough suppressants (dextromethorphan or codeine) for dry, bothersome cough. 1, 3
Agents to AVOID
Do not prescribe expectorants, mucolytics, antihistamines, or bronchodilators for acute viral URI—they have no proven benefit. 1, 3 β-agonists have not been shown to benefit patients without asthma or COPD. 1
Antibiotic Stewardship: When NOT to Prescribe
Antibiotics are contraindicated for uncomplicated viral URI because: 1, 2, 3
- They do not shorten illness duration
- They do not reduce work loss
- They do not prevent complications
- The number needed to harm (8) exceeds the number needed to treat (18) 3
Avoid macrolides (azithromycin) for viral URIs—one study showed significantly more adverse events than placebo, and this practice drives antimicrobial resistance. 1, 3
Red Flags: When to Consider Bacterial Superinfection
Consider antibiotics ONLY when specific criteria for bacterial complications are met: 2, 3
Acute Bacterial Rhinosinusitis (ABRS)
Antibiotics are indicated when at least one of the following is present: 3
- Persistent symptoms >10 days without improvement
- Severe symptoms ≥3 consecutive days with high fever (>39°C) plus purulent nasal discharge or facial pain
- "Double sickening"—worsening after initial improvement during days 5–7
Group A Streptococcal Pharyngitis
Confirm diagnosis with rapid antigen detection test (RADT) and/or throat culture before prescribing antibiotics. 3, 6
First-line therapy for confirmed GAS pharyngitis is amoxicillin for 10 days. 3
Special High-Risk Populations
Consider a lower threshold for antibiotics in: 1, 3
- Adults aged >75 years with fever
- Cardiac failure
- Insulin-dependent diabetes mellitus
- Serious neurological disorders (e.g., recent stroke)
Patient Education and Follow-Up
Expected Timeline
Inform patients that most symptoms resolve within 7–10 days, with symptom duration up to 2 weeks remaining within the normal viral trajectory. 2, 4
Return Precautions
Instruct patients to seek further evaluation if: 2, 3
- Fever lasting >3–4 days or recurring after initial improvement
- Symptoms persisting >10 days without any improvement
- Emergence of severe signs (high fever >39°C with purulent discharge for ≥3 consecutive days)
- "Double sickening" pattern
- Worsening dyspnea, inability to maintain oral intake, or declining consciousness 3
Addressing Patient Expectations
Do not prescribe antibiotics due to patient pressure—clinical criteria must guide prescribing decisions. 3
Explain that antibiotics cause adverse effects (diarrhea, rash, rare severe reactions) and promote antimicrobial resistance. 3
Common Pitfalls to Avoid
Do not interpret purulent discharge as bacterial infection—this is due to inflammatory cells and sloughed epithelial cells, not bacteria. 1, 3
Do not prescribe antibiotics within the first 10 days based on symptom duration alone—this represents normal viral course. 4
Do not use symptom severity alone as justification for antibiotics—viral URIs can cause significant symptoms that resolve without antimicrobial therapy. 2, 6
Public Health Impact
Excessive antibiotic prescribing for viral URIs contributes to antimicrobial resistance, imposes unnecessary healthcare costs, and exposes patients to avoidable adverse drug events. 2, 3, 6