What are the typical symptoms and recommended treatment regimen for upper respiratory tract infections (URTIs) in otherwise healthy adults and children?

Upper Respiratory Tract Infections: Symptoms and Treatment

Typical Symptoms

Viral URTIs present with a predictable constellation of symptoms that evolve over 5-14 days, including rhinorrhea, nasal congestion, sneezing, sore throat, cough, low-grade fever, headache, and malaise. 1, 2

Symptom Timeline and Evolution

• Days 0-2: Sneezing, clear watery rhinorrhea, sore throat, and low-grade fever predominate 1, 2
• Days 3-6: Symptoms peak; nasal discharge becomes thicker and may turn yellow-green (this is normal neutrophil activity, NOT bacterial infection) 1, 3
• Days 7-10: Nasal congestion and cough persist while fever and sore throat resolve 1, 2
• Days 10-14: Gradual resolution; approximately 7-13% of children (especially those in daycare) may have symptoms lasting beyond 15 days 1, 2

Key Clinical Features

• Fever, when present, typically resolves within 24-48 hours and occurs early in the illness 2
• Nasal discharge color changes from clear to purulent and back to clear—this progression is normal and does NOT indicate bacterial superinfection 1, 3
• Cough and nasal drainage are the most persistent symptoms, commonly lasting into the second week 1
• Ear fullness may occur due to eustachian tube dysfunction from nasal congestion 3

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Treatment Regimen

First-Line Symptomatic Management (All Patients)

Antibiotics should NEVER be prescribed for viral URTIs—they provide zero benefit, cause adverse effects in up to 44% of patients, and drive antimicrobial resistance. 1, 2, 3

Core Supportive Measures

• Analgesics/Antipyretics: Acetaminophen 1000mg every 4-6 hours (maximum 4g/24h) or ibuprofen for pain, headache, and fever 1, 3
• Nasal saline irrigation: 2-3 times daily to clear secretions and reduce congestion 1, 2, 3
• Adequate hydration and rest 2
• Proper hand hygiene to prevent transmission 1, 3

Additional Symptomatic Options

• Zinc lozenges: ≥75mg/day (acetate or gluconate) started within 24 hours of symptom onset may shorten duration, but weigh against adverse effects (nausea, bad taste) 3
• Topical nasal decongestants (oxymetazoline): Use ONLY for severe congestion and limit to 3-5 days maximum to prevent rebound rhinitis medicamentosa 3
• Oral decongestants (pseudoephedrine): May relieve congestion but avoid in patients with hypertension, cardiac disease, glaucoma, or bladder obstruction 3

Ineffective Therapies to Avoid

• Vitamin C and echinacea have no proven benefit 3
• Intranasal corticosteroids provide no meaningful relief for common cold 3
• Antihistamines have more adverse effects than benefits unless allergy is present 1

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When Antibiotics ARE Indicated: Acute Bacterial Rhinosinusitis

Reserve antibiotics ONLY for patients meeting specific criteria for bacterial rhinosinusitis—NOT for uncomplicated viral URTIs. 1, 2

Three Diagnostic Patterns for Bacterial Infection

Antibiotics should be considered when patients exhibit ONE of the following: 1, 2, 3

1. Persistent symptoms: ≥10 days without clinical improvement
2. Severe onset: High fever ≥39°C (102.2°F) with purulent nasal discharge AND facial pain for at least 3-4 consecutive days
3. Double worsening: Initial improvement followed by worsening symptoms after day 5

Antibiotic Selection When Indicated

• First-line (adults and children): Amoxicillin 45mg/kg/day divided twice daily 1, 2, 4
• High-resistance areas or recent antibiotic exposure: High-dose amoxicillin 90mg/kg/day 1, 2
• Treatment failure or recent antibiotic use: Amoxicillin-clavulanate 90mg/6.4mg per kg per day 1, 2
• Duration: Continue for minimum 48-72 hours beyond symptom resolution 4

Evidence for Antibiotic Efficacy in True Bacterial Sinusitis

• In properly diagnosed acute bacterial rhinosinusitis, cure rates increase from 14% with placebo to 50% with amoxicillin-clavulanate 1, 2
• However, adverse effects (primarily diarrhea) occur in 40-44% of antibiotic-treated patients 1, 2
• Number needed to treat is 18 for one cure, but number needed to harm is only 8 1

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Critical Red Flags Requiring Immediate Evaluation

Seek urgent medical attention for: 2, 3

• Severe headache, visual changes, or periorbital swelling (concern for orbital cellulitis)
• Altered mental status or cranial nerve deficits (concern for intracranial complications)
• Persistent high fever >3 days
• Signs of respiratory distress

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Common Pitfalls to Avoid

• DO NOT prescribe antibiotics based on purulent nasal discharge alone—this reflects normal neutrophil activity in viral infections, not bacterial infection 1, 3
• DO NOT obtain imaging studies to distinguish viral from bacterial infection—up to 87% of viral URIs show sinus abnormalities on CT, leading to unnecessary interventions 1, 3
• DO NOT extend topical decongestant use beyond 5 days—this causes rebound congestion requiring prolonged therapy 3
• DO NOT use over-the-counter cough/cold medications in children under 3-6 years due to potential adverse effects 2, 3

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Special Populations: Pediatric Considerations

• Children experience 3-8 viral URIs per year with mean duration 6.6-8.9 days 1
• Children in daycare have more protracted symptoms (up to 13% lasting >15 days) 1, 2
• Avoid decongestants and antihistamines in children under 3 years 2, 3
• Use age-appropriate dosing for all medications 2