From the Guidelines
Viral upper respiratory infections (URIs) should be distinguished from bacterial URIs based on the duration and severity of symptoms, with bacterial URIs typically requiring antibiotic treatment if symptoms persist beyond 10 days or worsen after initial improvement, as recommended by the clinical practice guideline update for adult sinusitis 1. The distinction between viral and bacterial URIs is crucial to prevent unnecessary antibiotic use and reduce the risk of antibiotic resistance. Viral URIs are more common, accounting for about 90% of all URIs, and are caused by viruses like rhinovirus, coronavirus, or influenza. They typically present with gradual onset of symptoms including runny nose, congestion, sore throat, cough, and low-grade fever. Treatment is primarily supportive with rest, hydration, over-the-counter pain relievers like acetaminophen (325-650mg every 4-6 hours) or ibuprofen (400-600mg every 6-8 hours), and decongestants.
Key Differences Between Viral and Bacterial URIs
- Viral URIs:
- Caused by viruses like rhinovirus, coronavirus, or influenza
- Typically present with gradual onset of symptoms
- Symptoms include runny nose, congestion, sore throat, cough, and low-grade fever
- Treatment is primarily supportive
- Bacterial URIs:
- Caused by bacteria such as Streptococcus pneumoniae or Haemophilus influenzae
- Often present with more severe symptoms including high fever, purulent (colored) nasal discharge, facial pain, and symptoms persisting beyond 10-14 days
- Typically require antibiotic treatment, such as amoxicillin (500mg three times daily for 7-10 days) or azithromycin (500mg on day 1, then 250mg daily for 4 days)
Diagnosis and Treatment
A clinician should diagnose acute bacterial rhinosinusitis (ABRS) when symptoms or signs of acute rhinosinusitis persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms or worsen within 10 days after an initial improvement, as stated in the clinical practice guideline update for adult sinusitis 1. The clinical practice guideline update for adult sinusitis also emphasizes the importance of distinguishing presumed ABRS from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions to prevent unnecessary treatment with antibiotics and reduce healthcare costs 1. If symptoms are severe or persist beyond 10-14 days, worsen after initial improvement, or include high fever and purulent discharge, medical evaluation is recommended as these suggest possible bacterial infection.
From the Research
Viral vs Bacterial Upper Respiratory Tract Infections (URTI)
- Upper respiratory tract infections (URTIs) include the common cold, rhinosinusitis, pharyngitis, and acute otitis media (AOM) 2.
- URTIs are typically viral, but they are the most common reason for prescription of antibiotics in adults 2.
- A bacterial etiology is more likely if symptoms last longer than 10 days, the temperature is greater than 39°C (102.2°F), or if symptoms worsen after initial improvement 2.
Diagnosis and Treatment
- Antibiotics are not recommended unless symptoms worsen or do not improve after an additional 7 days 2.
- Acute pharyngitis is typically of viral origin, and antibiotics for streptococcal pharyngitis should be prescribed only if test or culture results are positive 2.
- The use of antibiotics for acute otitis media, sore throat, and streptococcal tonsillitis seems to be discretionary rather than prohibited or mandatory, at least for non-severe cases 3.
- There is good evidence and consensus that there is no indication for antibiotics for the common cold 3.
Management Strategies
- Early intervention is crucial in managing acute URTIs, and mucoadhesive gel nasal sprays have shown promising results for early intervention 4.
- The effectiveness of management strategies is highly increased with early intervention, administered prior to the peaking of viral shedding 4.
- Antibiotics should not be used for the common cold, influenza, COVID-19, or laryngitis, but evidence supports antibiotic use in most cases of acute otitis media, group A beta-hemolytic streptococcal pharyngitis, and epiglottitis 5.
Antibiotic Use
- Inappropriate antibiotic use results in adverse events, contributes to antibiotic resistance, and adds unnecessary costs 5.
- Family physicians must take an evidence-based, judicious approach to the use of antibiotics in patients with upper respiratory tract infections 5.
- Several evidence-based strategies have been identified to improve the appropriateness of antibiotic prescribing for acute upper respiratory tract infections 5.