Upper Respiratory Tract Infection Medication
- Author: Anne Meneghetti, MD; Chief Editor: Zab Mosenifar, MD more...
Medication Summary
Therapy addressing specific symptoms is the mainstay for most URIs. Most URIs are self-limited viral infections that resolve without prescription drugs.
In terms of symptomatic treatment, combination analgesic-antihistamine-decongestants have shown mixed results in studies. A Cochrane review suggested some benefit in terms of recovery and symptoms with combination antihistamine-decongestants in adults and older children. However, any benefits need to be weighed against the risk of adverse effects such as drowsiness, dizziness, dry mouth and insomnia.[35]
Recognizing viral and bacterial diseases for which specific therapy is available is important. Antibacterial therapy is appropriate for patients with group A streptococcal pharyngitis, bacterial sinusitis, epiglottitis, pertussis, or diphtheria. Patients with HSV infection or gonococcal upper airway disease also benefit from specific treatment. In immunocompromised patients, treatment of RSV and cytomegalovirus infections may be appropriate, especially if lower airway disease is suspected.
In general, antivirals do not provide clinical benefits in persons with viral pharyngitis. However, in patients who are immunocompromised, antivirals have a role in treating illness that might progress. Acyclovir, famciclovir, and valacyclovir are recommended for patients with severe HSV pharyngitis and for immunocompromised patients. Foscarnet or ganciclovir are recommended for the treatment of cytomegalovirus infections in immunocompromised patients. For management of patients with suspected or confirmed seasonal or H1N1 influenza, see the eMedicine article on this topic.
Antibiotics used in specific conditions are as follows:
Group A streptococcal infection
- Penicillin V (Beepen-VK, Betapen-VK, Veetids, V-Cillin K)
- Amoxicillin (Trimox, Wymox)
- Penicillin G benzathine (Bicillin L-A, Permapen)
- Cefadroxil (Duricef)
- Erythromycin (E.E.S., Erythrocin, E-Mycin, Eryc)
- Amoxicillin and clavulanate (Augmentin)
- Cefaclor (Ceclor)
- Cefuroxime (Ceftin)
- Ceftriaxone (Rocephin)
- Azithromycin (Zithromax)
Epiglottitis
- Cefuroxime (Ceftin)
- Ceftriaxone (Rocephin)
- Cefotaxime (Claforan)
Pertussis
- Clarithromycin (Biaxin)
- Erythromycin (E-Mycin, Erythrocin, Eryc, Ery-Tab, E.E.S.)
- Azithromycin (Zithromax)
Antibiotics
Class Summary
- Group A streptococcal infections: Antibiotics are appropriate for patients with group A streptococcal pharyngitis.
- Epiglottitis: For epiglottitis, cephalosporins such as cefuroxime, ceftriaxone, or cefotaxime are commonly used empirically. Oxacillin, nafcillin, and clindamycin are also options.
- Pertussis: Pertussis is treated with macrolides.
Penicillin V (Beepen-VK, Betapen-VK, Veetids, V-Cillin K)
Considered antimicrobial agent of choice for treatment of group A streptococcal pharyngitis.
Amoxicillin (Trimox, Wymox)
Equivalent for bacteriologic eradication of group A streptococcal infection from tonsillopharynx. Appropriate for uncomplicated bacterial rhinosinusitis.
Penicillin G benzathine (Bicillin L-A, Permapen)
Antimicrobial agent of choice for treatment of group A streptococcal pharyngitis.
Cefadroxil (Duricef)
Used for epiglottitis and for resistant rhinosinusitis.
Erythromycin (E.E.S., Erythrocin, E-Mycin, Eryc)
Group A streptococcal infection
Macrolides are appropriate for patients with penicillin sensitivity, for some with rhinosinusitis, and for those with pertussis and diphtheria.
Pertussis
Recommended dosing schedule of erythromycin may result in GI upset, causing prescription of alternative macrolide or change to tid dosing. Covers most potential etiologic agents, including Mycoplasma species.
Erythromycin is less active against H influenzae.
Although 10 d seems to be standard course of treatment, treating until patient has been afebrile for 3-5 d seems more rational. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Indicated for staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Has the added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.
Amoxicillin and clavulanate (Augmentin)
Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase producing bacteria.
Good alternative antibiotic for patients allergic to or intolerant of macrolide class. Usually well tolerated and provides good coverage of most infectious agents. Not effective against Mycoplasma and Legionella species. Half-life of oral form is 1-1.3 h. Has good tissue penetration but does not enter cerebrospinal fluid.
For children >3 mo, base dosing on amoxicillin content. Due to different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250 mg chewable-tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Cefaclor (Ceclor)
Second-generation cephalosporin that binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity. Has gram-positive activity that first-generation cephalosporins have and adds activity against Proteus mirabilis, H influenzae, E coli, Klebsiella pneumoniae, and M catarrhalis. Indicated for management of infections caused by susceptible mixed aerobic-anaerobic microorganisms. Determine proper dosage and route based on condition of patient, severity of infection, and susceptibility of causative organism.
Cefuroxime (Ceftin)
Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins; adds activity against P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis.
Binds to penicillin-binding proteins and inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration. Resists degradation by beta-lactamase.
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections.
Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life. Shown to be effective for pertussis in several small studies.
Clarithromycin (Biaxin)
Semisynthetic macrolide antibiotic that reversibly binds to P site of 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl t-RNA from ribosomes, causing bacterial growth inhibition.
Cefotaxime (Claforan)
Third-generation cephalosporin with broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis by binding to one or more penicillin-binding proteins, which, in turn, inhibits bacterial growth. Safety profile more favorable than aminoglycosides.
Analgesic antipyretics
Class Summary
These agents reduce pain and fever.
Acetaminophen (Tylenol, Feverall, Tempra)
DOC for pain in patients with documented hypersensitivity to aspirin, NSAIDs, upper GI disease, or those taking oral anticoagulants. Reduces fever by directly acting on hypothalamic heat-regulating centers, increasing dissipation of body heat by means of vasodilation and sweating.
Anticholinergic agents
Class Summary
Parasympatholytic inhalers inhibit vagally mediated reflexes by antagonizing the action of acetylcholine released by the vagus nerve. This action prevents the increase in intracellular concentration of cGMP caused by interaction of acetylcholine and muscarinic receptors on bronchial smooth muscle. Help reduce mucus in lungs and relax smooth muscles of large and medium bronchi. May be used with short-acting beta2-adrenergic bronchodilators.
Ipratropium (Atrovent)
Chemically related to atropine. Has antisecretory properties. When applied locally, inhibits secretions from serous and seromucous glands lining nasal mucosa.
Antihistamines
Class Summary
These agents act by competitively inhibiting histamine at the H1 receptor. This effect mediates bronchial constriction, mucous secretion, smooth muscle contraction, and edema.
Diphenhydramine (Benadryl, Benylin)
First-generation antihistamine with anticholinergic effects.
Chlorpheniramine (Aller-Chlor, Chlo-Amine, Chlor-Trimeton, Telachlor)
First-generation agent that competes with histamine or H1-receptor sites on effector cells in blood vessels and respiratory tract. One of the safest antihistamines to use during pregnancy.
Brompheniramine (Bromphen, Dimetane Extentabs, Nasahist B)
Does not tend to cause drowsiness and is suitable to use on a day-to-day basis. Oral H1 blocker used for allergic conjunctivitis and rhinitis, angioedema, pruritus, and urticaria.
Antitussives
Class Summary
Several agents are intended for the symptomatic relief of cough. However, evidence is mixed regarding effectiveness of these agents. While codeine may inhibit cough under various circumstances, data are limited regarding its effectiveness in reducing acute cough due to URI. Dextromethorphan has resulted in cough reduction compared with placebo in some studies. However, one study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI.[36] Guaifenesin studies have shown mixed results. Cough and cold medicines should be used with caution in children younger than 2 years because serious adverse reactions and fatalities have occurred with OTC preparations.[37] Many OTC cough and cold preparation labels state that the product should not be used in children younger than 4 years.
Guaifenesin and dextromethorphan (Benylin, Humibid, DM, Mytussin, Robitussin DM, Tuss DM)
Treats minor cough resulting from bronchial and throat irritation.
Codeine
Centrally acting antitussive. Helps manage pain of intercostal muscle strain associated with cough.
Adrenergic agonists
Class Summary
Alpha stimulation causes mucosal vasoconstriction, decreasing edema of the subglottic region of the larynx. Although inhaled epinephrine is sometimes given in epiglottitis, its benefit is unproven.
Epinephrine (Adrenalin)
For severe bronchoconstriction, especially with underlying reactive airway disease. Alpha-agonist effects include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Beta2-agonist effects include bronchodilatation, chronotropic cardiac activity, and positive inotropy.
Corticosteroids
Class Summary
Steroids are used to decrease edema by suppressing local inflammation. They are frequently used to manage croup, and they may reduce the need for racemic epinephrine inhalation.
Dexamethasone (Decadron, AK-Dex, Alba-Dex, Baldex)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Prednisone in equivalent doses may be substituted if administered over 5 d.
Decongestants
Class Summary
These drugs are typically used to relieve nasal symptoms in a variety of URIs. Decongestants and antihistamines should be used with caution in children younger than 2 years because serious adverse reactions and fatalities have occurred with OTC cough and cold preparations.[37] In 2008, the Consumer Healthcare Products Association modified many OTC cough and cold product labels to state "do not use" in children younger than 4 years.[38]
Pseudoephedrine (Actifed, Afrin, Sudafed)
Stimulates vasoconstriction by directly stimulating alpha-adrenergic receptors in respiratory mucosa. Used for symptomatic relief of nasal congestion due to common cold, upper respiratory tract allergies, and sinusitis. Promotes nasal or sinus drainage.
Phenylephrine nasal (Neo-Synephrine)
Strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity that produces vasoconstriction of arterioles in the body.
Oxymetazoline (Allerest, Afrin, Dristan, Chlorphed)
Stimulates alpha-adrenergic receptors and causes vasoconstriction when applied directly to mucous membranes. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.
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| Symptom | Allergy | URI | Influenza |
| Itchy, watery eyes | common | rare; conjunctivitis may occur with adenovirus | soreness behind eyes, sometimes conjunctivitis |
| Nasal discharge | common | common | common |
| Nasal congestion | common | common | sometimes |
| Sneezing | very common | very common | sometimes |
| Sore throat | sometimes (postnasal drip) | very common | sometimes |
| Cough | sometimes | common, mild to moderate, hacking cough | common, dry cough, can be severe |
| Headache | uncommon | rare | common |
| Fever | never | rare in adults, possible in children | very common, 100-102°F or higher (in young children), lasting 3-4 days; may have chills |
| Malaise | sometimes | sometimes | very common |
| Fatigue, weakness | sometimes | sometimes | very common, can last for weeks, extreme exhaustion early in course |
| Myalgias | never | slight | very common, often severe |
| Duration | weeks | 3-14 days | 7 days, followed by additional days of cough and fatigue |
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