Overuse of outpatient antibiotics has contributed to the emergence and spread of penicillin-resistant pneumococci. Most URTIs are caused by viral pathogens and only rarely require antibiotics. Inappropriate antibiotics increase the risk of allergic reactions (urticaria, rash, anaphylaxis), adverse reactions (gastrointestinal, yeast infections) and drug-drug interactions.
Management of URTIs in Immunocompetent Adults
| Usual pathogen | Diagnosis | Treatment | Comments | |
|---|---|---|---|---|
| Nonspecific URTI (Common cold) | Rhinovirus Adenovirus RSV Consider influenza or parainfluenza if prominent systemic symptoms | Nasopharyngeal swab (NPS) | Symptomatic relief | Purulent nasal or pharyngeal discharge common with uncomplicated viral infection Consider empiric oseltamivir (Tamiflu) if high risk for influenza |
| Acute sinusitis (Symptoms < 4 weeks) | > 98% viral If bacterial: Streptococcus pneumoniae Haemophilus influenzae | Routine Xray or CT not helpful | Symptomatic relief | Reserve antibiotics if symptoms last ≥ 10d , facial pain > 3d, fever of ≥ 39 plus purulent discharge |
| Acute pharyngitis | Usually viral Group A strep (10%) Consider gonococcus, EBV, acute HIV | Rapid strep Request culture if rapid test is negative but high index of suspicion | If Group A Strep: penicillin (if true anaphylactic reaction to penicillin, consider macrolide or clindamycin) | Centor Criteria: tonsillar exudates. tender lymph nodes, absence of cough, fever. If all present, testing for GAS is indicated |
| Acute bronchitis (Cough ≤ 3 wks) | Usually viral 5%-10% secondary to pertussis, mycoplasma or chlamydia | Routine sputum gram stain or culture not helpful | Symptomatic relief Consider treatment for pertussis if high chance of exposure (eg epidemic) | Consider pneumonia if: HR ≥ 100, ≥ 24 , T ≥ 38≥C OR focal lung exam |
Annals of Internal Medicine 2001