eMedicine Specialties > Pulmonology > Infectious Lung Diseases

Upper Respiratory Tract Infection: Treatment & Medication

Author: Anne Meneghetti, MD, Assistant Professor of Medicine, Tufts University School of Medicine; Medical Broadcaster, Life, Love and Health
Contributor Information and Disclosures

Updated: Aug 12, 2009

Treatment

Medical Care

Most URIs are self-diagnosed and self-treated at home. Patients who present with infections often benefit from reassurance, education, and instructions for symptomatic home treatment. Antimicrobial therapy is appropriate in selected patients (see Medication). Several URIs warrant special attention. These are described below.

Epiglottitis

The risk for airway compromise is notable, especially in children. Immediately transfer the patient to the nearest hospital. Adults with epiglottitis typically have a relatively gradual course. However, some older children and adults may have respiratory compromise, especially those with congenital or acquired subglottic stenosis. The treatment of epiglottitis in adults requires individual tailoring of therapy on the basis of the severity of disease at presentation and the course of the disease as it unfolds under observation.

• Instrumentation: Avoid instrumentation. In suspected epiglottitis, limit the examination to observation and an assessment of the vital signs. Tongue depressors or other instruments may provoke airway spasm and precipitate respiratory compromise. Keep the patient comfortable, and avoid unnecessary examinations.
• Specialist consult: An anesthesiologist or otorhinolaryngologist should be involved early in the management of epiglottitis.
• Monitoring: Patients must be monitored for respiratory fatigue visually and with continuous pulse oximetry. Accessibility to equipment and expertise for immediate intubation is required in the event of respiratory failure. If endotracheal intubation is not possible, cricothyroidotomy may be required.
• Oxygen: Oxygen is administered according to pulse oximetry results. Dry air may worsen inflammation. Use of humidified oxygen or a room humidifier is recommended.
• Antibiotics: Presumptive intravenous antibiotics are indicated, tailored to results from blood cultures.
• Glucocorticoids: Either intravenous or inhaled glucocorticoids are sometimes given to reduce inflammation. However, controlled trials of the effectiveness of this approach in epiglottitis are limited.
• Volume deficits: Correct volume deficits with intravenous fluids.
• Sedatives: Avoid sedatives that may suppress the respiratory drive.
• Other medications: In patients with croup, aerosolized racemic epinephrine is sometimes used to reduce mucosal edema; however, the role of this drug in persons with epiglottitis is not defined. Adverse events have been reported in patients with epiglottitis.²⁴ Beta-2 agonists are not typically used in patients who do not have asthma.

Laryngotracheitis

Patients may require hospitalization, especially infants and young children who have hypoxemia, volume depletion, a risk for airway compromise, or respiratory fatigue. Mild cases of croup (ie, laryngotracheobronchitis) may be managed at home with moist air inhalation. Patients with diphtheria may require isolation and hospitalization for airway management. The following measures apply to hospitalized patients:

• Monitoring: Patients are monitored for respiratory fatigue visually and with continuous pulse oximetry. Expertise for immediate intubation and access to the necessary equipment are required if respiratory failure is a possibility. If endotracheal intubation is not possible, cricothyroidotomy is indicated for respiratory failure. Keep the patient comfortable, and avoid unnecessary procedures and examinations.
• Oxygen therapy: Administer humidified oxygen to all hypoxemic patients. In patients who do not require oxygen therapy, a cool-mist humidifier may be used. Dry air may worsen inflammation. Heliox, a mixture of helium and oxygen, compared favorably with inhaled racemic epinephrine in a small study of pediatric patients with moderate-to-severe croup.²⁵
• Glucocorticoids: Intravenous or oral glucocorticoids are commonly used to reduce symptoms and shorten hospitalization in patients with moderate-to-severe croup. Inhaled steroids may be considered in cases that are not severe; however, evidence from large controlled trials regarding the use of inhaled steroids in croup is lacking.
• Antibiotic therapy: Antibiotics are appropriate for whooping cough (pertussis); however, croup is typically a viral condition. Blood cultures are ordered.
• Volume deficit: Correct volume deficits with intravenous fluids.
• Sedatives: Avoid sedatives that may suppress the patient's respiratory drive.
• Other medications: Inhaled racemic epinephrine may temporarily dilate the airways by relaxing bronchial smooth muscle and causing vasoconstriction that may reduce mucosal inflammation. Epinephrine may be considered in patients with persistent stridor. Because rebound edema may occur when inhaled epinephrine is stopped, monitoring and observation is required for several hours afterward. The use of steroids may reduce the need for epinephrine to manage croup. In persons with whooping cough, evidence is insufficient to justify the use of long-acting beta-agonists, antihistamines, or pertussis immunoglobulin.²⁶

Deep tissue infections

Retropharyngeal abscess, intracranial abscess, or other deep tissue infection may compromise the airway, vision, or neurologic function. Patients with evidence of intraorbital or intracranial extension of suppurative infection warrant hospitalization, imaging, and surgical consultation. Antibacterial therapy is often warranted.

Patients with immunocompromise

Special attention is warranted in patients with suboptimal immune defenses. This includes patients without a spleen, those with HIV infection, patients with cancer or those undergoing cancer therapy, patients receiving dialysis, those undergoing stem cell or organ transplantation, or those with congenital immunodeficiency. Splenectomy lowers a patient's ability to fight infections with encapsulated organisms. Appropriate antimicrobial therapy and close follow-up may be appropriate because a simple URI may quickly progress to a systemic illness in immunocompromised patients. Although the threshold for hospitalization is lowered for these patients, their risks of nosocomial infections must be weighed against the benefits of close monitoring in the inpatient setting.

Surgical Care

Deep tissue infections of adjacent structures, such as a peritonsillar, oropharyngeal, or intracranial abscess, warrant immediate consultation with a surgeon. 

Repeated streptococcal infection may be an indication for surgical intervention. In patients with 4-5 confirmed group A streptococcal infections in a single year or in those with chronic sore throat with adenopathy that is  not responsive to treatment over 6 months, tonsillectomy may be considered.

Complicated sinus disease may warrant surgical intervention, but surgery is rarely warranted in acute rhinosinusitis. Surgery may be considered when the condition has not responded to months of medical therapy, when a mucopyocele is present, when a fungal sinus infection occurs, or when infection extends to the bone. If possible, the sinus mucosa should be left intact. Functional endoscopic sinus surgery is designed to promote drainage of the sinuses by altering the ostiomeatal complex. For surgical management of chronic sinusitis, see the eMedicine article Sinusitis, Chronic.

Consultations

• Surgeon: Airway obstruction from epiglottitis, tonsillar hypertrophy, peritonsillar abscess, retropharyngeal abscess, or other mass requires emergency consultation by a surgeon. Sleep apnea associated with tonsillar hypertrophy may also prompt surgical consultation.
• Neurosurgeon: Neurologic findings or mental status changes in the setting of suspected intracranial suppurative complications warrant emergency consultation with a neurosurgeon.
• Infectious disease specialist: Consider consulting an infectious disease specialist when patients have HIV infection, cancer-related or congenital immunodeficiency, or other immunocompromise.
• Pulmonologist or otorhinolaryngologist: Patients with a chronic cough after a URI may benefit from a consultation with a pulmonologist or otorhinolaryngologist to evaluate persistent infection, asthma, gastroesophageal reflux disease, or other causes of chronic cough. Patients with 4-5 confirmed group A streptococcal infections in a single year or those with a chronic sore throat and adenopathy unresponsive to treatment over 6 months should be examined by an infectious disease specialist and/or surgeon. Persistent hoarseness after 2 weeks warrants consultation with an otorhinolaryngologist.

Diet

• Fluid intake: Increased fluids are warranted to replace insensible losses and reduced oral intake.
• Probiotics: Antibiotics alter the gastrointestinal flora, and some foods may not be as digestible for days or weeks after antibiotics are used. Consumption of yogurt containing active cultures has been advocated as an aid to restoring normal flora after antibiotic therapy. A meta-analysis suggests that probiotics may prevent antibiotic-associated diarrhea; Saccharomyces boulardii and lactobacilli may be particularly useful in this situation.²⁷
• Alcohol intake: Alcohol may cause swelling of the nasal and paranasal sinus mucosae.

Activity

• Rest: Patients with the common cold may consider returning to their usual physical activity, including aerobic activity, if their symptoms are limited to the nose and throat. However, if cough, fever, or other systemic symptoms are present, rest is indicated. Rest is helpful for recovery from an URI.
• Contact sports: Patients with infectious mononucleosis should be instructed to avoid contact sports for 6 weeks because of the possibility of splenic rupture.
• Voice rest: This is indicated for patients with laryngitis or laryngotracheitis.
• Air travel: Patients may experience increased discomfort from upper airway infection during air travel. As atmospheric pressure drops during takeoff, expansion of soft tissues may block the eustachian tubes and increase pressure sensations in the sinuses.
• Swimming: Chlorine from pools may be irritating to inflamed nasal membranes. Diving, especially at depth, may cause uncomfortable pressure and impair drainage of the paranasal sinuses.

Medication

Therapy addressing specific symptoms is the mainstay for most URIs. Most URIs are self-limited viral infections that resolve without prescription drugs. 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 H1N1 influenza, see the eMedicine article on this topic.

Antibiotics: Group A streptococcal agents

Antibiotics are appropriate for patients with group A streptococcal pharyngitis.

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)

Macrolides are appropriate for patients with penicillin sensitivity, for some with rhinosinusitis, and for those with pertussis and diphtheria.

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.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse as a result of the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding has been reported to decrease from 95% bound at plasma concentrations <25 mcg/mL to 85% bound at 300 mcg/mL.
Indicated for cases of gonococcal pharyngitis. DOC for epiglottitis.

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.

Antibiotics: Epiglottitis

For epiglottitis, cephalosporins such as cefuroxime, ceftriaxone, or cefotaxime are commonly used empirically. Oxacillin, nafcillin, and clindamycin are also options.

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.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse as a result of ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding has been reported to decrease from 95% bound at plasma concentrations <25 mcg/mL to 85% bound at 300 mcg/mL.

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.

Antibiotics: Pertussis

Pertussis is treated with macrolides.

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.

Erythromycin (E-Mycin, Erythrocin, Eryc, Ery-Tab, E.E.S.)

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.

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.

Analgesic antipyretics

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

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

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 maleate (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

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.²⁸ 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.²⁹ 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

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

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

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.²⁹ 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.³⁰

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 (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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