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Medication

Medication Summary

Therapy addressing specific symptoms is the mainstay for most upper respiratory infections (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. Awareness of local trends in prevalent organisms and local resistance patterns is key. Antibacterial therapy is appropriate for patients with any of the following:

Group A streptococcal pharyngitis
Bacterial sinusitis
Epiglottitis
Pertussis
Diphtheria

Antibiotics used in group A streptococcal infection are as follows:

Penicillin VK (Penicillin V)
Amoxicillin (Amoxil, Moxatag, Trimox)
Penicillin G benzathine (Bicillin LA, Permapen)
Cefadroxil (Duricef)
Erythromycin (E.E.S., Erythrocin, E-Mycin, Eryc)
Amoxicillin and clavulanate (Augmentin, Augmentin XR)
Cefaclor (Ceclor)
Cefuroxime (Ceftin)
Ceftriaxone (Rocephin)
Azithromycin (Zithromax)

Antibiotics used in epiglottitis are as follows:

Cefuroxime (Ceftin)
Ceftriaxone (Rocephin)
Cefotaxime (Claforan)

Antibiotics used in pertussis are as follows:

Clarithromycin (Biaxin)
Erythromycin (E-Mycin, Erythrocin, Eryc, Ery-Tab, E.E.S.)
Azithromycin (Zithromax)

Antibiotics used in acute bacterial rhinosinusitis are as follows:

Amoxicillin/clavulanate
Doxycycline

The US Food and Drug Administration (FDA) has warned that azithromycin may lead to QT interval prolongation and torsades de pointes. The FDA notes that "health care professionals should consider the risk of fatal heart rhythms with azithromycin when considering treatment options for patients who are already at risk for cardiovascular events." These include patients with known QT interval prolongation, torsades de pointes, congenital long QT syndrome, bradyarrhythmias, or uncompensated heart failure.^[72]

Patients with herpes simplex virus (HSV) infection or gonococcal upper airway disease also benefit from specific treatment. In immunocompromised patients, treatment of respiratory syncytial virus (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 (CMV) in immunocompromised patients.

Cough and cold medicines should be used with caution in children younger than 2 years because serious adverse reactions and fatalities have occurred with over-the-counter preparations.^[51]In 2008, the Consumer Healthcare Products Association modified many over-the-counter cough and cold product labels to state "do not use" in children younger than 4 years.^[52]

Class Summary

Penicillins are highly active against gram-positive organisms. Their bactericidal activity is the result of interfering with bacterial cell wall synthesis

Penicillin VK (Penicillin V)

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Penicillin is the antimicrobial agent of choice for treatment of group A streptococcal pharyngitis. It is indicated for the treatment of infections caused by susceptible organisms involving the respiratory tract.

Penicillin G benthazine (Bicillin LA, Permapen)

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Penicillin is the antimicrobial agent of choice for treatment of group A streptococcal pharyngitis. It is indicated for the prophylaxis or treatment of mild to moderately severe upper respiratory tract infections caused by organisms susceptible to low concentrations of penicillin G.

Class Summary

Penicillins inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins.

Ampicillin (Ampi, Omnipen, Penglobe, Principen)

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Ampicillin is a second-generation penicillin that is active against many strains of Escherichia coli, Proteus mirabilis, Salmonella, Shigella, and Haemophilus influenzae. It is available in oral and injection forms.

Amoxicillin (Amoxil, Moxatag, Trimox)

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Amoxicillin is the equivalent of penicillin for bacteriologic eradication of group A streptococcal infection from the tonsillopharynx. It is also appropriate for uncomplicated bacterial rhinosinusitis. It is further indicated for the treatment of otitis media, sinusitis, and infections caused by susceptible organisms involving the upper and lower respiratory tract.

Amoxicillin/clavulanate (Augmentin, Augmentin XR, Augmentin ES-600)

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Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. The addition of clavulanate inhibits beta-lactamase producing bacteria. This combination is a good alternative for patients allergic to or intolerant of macrolide antibiotics. It is usually well tolerated and provides good coverage of most infectious agents, but it is not effective against Mycoplasma and Legionella species.

The half-life of oral amoxicillin/clavulanate is 1-1.3 hours. Amoxicillin has good tissue penetration but does not enter the cerebrospinal fluid.

For children over 3 months, base dosing on the amoxicillin content. Due to different amoxicillin/clavulanic acid ratios in 250-mg tablets (250/125) vs 250-mg chewable tablets (250/62.5), do not use the 250-mg tablet until the child weighs over 40 kg.

Class Summary

First-generation cephalosporins are active mainly against gram-positive bacteria. They inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins and eventually cause the bacteria to lyse.

Cefadroxil (Duricef, Ultracef)

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Cefadroxil is indicated for the treatment of susceptible bacterial infections, including those caused by group A beta-hemolytic Streptococcus.

Class Summary

The second-generation cephalosporins are less active against gram-positive bacteria than the first-generation agents are and are more active against certain gram-negative bacteria. Cephalosporins bind to penicillin-binding proteins and inhibit the final transpeptidation step of peptidoglycan synthesis, resulting in bacterial cell wall death.

Cefaclor (Ceclor)

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Cefaclor is a second-generation cephalosporin that binds to 1 or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity. It has the gram-positive activity that first-generation cephalosporins have and adds activity against P mirabilis, H influenzae, E coli, Klebsiella pneumoniae, and Moraxella catarrhalis.

This agent is indicated for management of infections caused by susceptible mixed aerobic-anaerobic microorganisms. Determine the proper dosage and route based on the condition of the patient, the severity of the infection, and the susceptibility of the causative organism.

Cefuroxime (Ceftin)

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Cefuroxime is a second-generation cephalosporin that maintains the gram-positive activity of first-generation cephalosporins and adds activity against P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis.

This agent binds to penicillin-binding proteins and inhibits the final transpeptidation step of peptidoglycan synthesis, resulting in bacterial cell wall death. The condition of the patient, the severity of the infection, and the susceptibility of the microorganism determine the proper dose and route of administration. Cefuroxime resists degradation by beta lactamase.

Class Summary

Third-generation cephalosporins are less active against gram-positive organisms compared with first-generation cephalosporins. They are highly active against Enterobacteriaceae, Neisseria, and H influenzae.

Cefotaxime (Claforan)

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Cefotaxime is a third-generation cephalosporin with a broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. It arrests bacterial cell wall synthesis by binding to 1 or more penicillin-binding proteins, which, in turn, inhibits bacterial growth. Its safety profile is more favorable than that of aminoglycosides.

Class Summary

Macrolides are appropriate for the treatment of group A streptococcal infection in patients with penicillin sensitivity. They are also used for some cases of rhinosinusitis, pertussis, and diphtheria. Macrolides block transpeptidation by binding to the 50S ribosome. They also inhibit RNA-dependent protein synthesis.

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

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Erythromycin covers most potential etiologic agents in rhinosinusitis, including Mycoplasma species; however, it is less active against H influenzae. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. It is indicated for treatment of staphylococcal and streptococcal infections. This agent has the added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.

In children, the patient's age and weight and the severity of the infection determine proper dosage. When twice-daily dosing is desired, half the total daily dose may be taken every 12 hours. For more severe infections, double the dose. The recommended dosing schedule of erythromycin may result in gastrointestinal upset. Patients may require an alternative macrolide or a change to 3-times-daily dosing. Although the standard course of treatment seems to be 10 days, treating until the patient has been afebrile for 3-5 days seems more rational.

Azithromycin (Zithromax)

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Azithromycin acts by binding to the 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.

This agent concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that the concentration in phagocytes may contribute to drug distribution to inflamed tissues.

Azithromycin is used for the treatment of mild to moderate microbial infections, including group A streptococcal infection and pertussis. Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. It has a long tissue half-life.

Clarithromycin (Biaxin)

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Clarithromycin is a semisynthetic macrolide antibiotic that reversibly binds to the P site of the 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.

Class Summary

These agents reduce pain and fever.

Acetaminophen (Tylenol, Feverall, Tempra)

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Acetaminophen is the drug of choice for pain relief in patients with documented hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), who have upper gastrointestinal disease, or who are taking oral anticoagulants. It reduces fever by directly acting on hypothalamic heat-regulating centers, increasing dissipation of body heat by means of vasodilation and sweating.

Class Summary

Nonsteroidal anti-inflammatory drugs (NSAIDs) are reversible inhibitors of cyclo-oxygenase–1 (COX-1) and COX-2 enzymes, which results in decreased formation of prostaglandin precursors. NSAIDs have antipyretic, analgesic, and anti-inflammatory properties.

NSAIDs typically contain a black-box warning about an increased risk of adverse cardiovascular thrombotic events, including myocardial infarction and stroke. Another black-box warning related to NSAIDs comments on the increased risk of gastrointestinal irritation, inflammation, ulceration, bleeding, and perforation with the use of these drugs.

Naproxen (Aleve, Naprosyn, Naproxen SR, Anaprox)

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Naproxen is indicated for mild to moderate pain. Other indications include ankylosing spondylitis, osteoarthritis, and rheumatoid disorders. Onset of action for relieving pain is typically 1 hour.

Ibuprofen (Motrin, NeoProfen, Caldolor, Advil)

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Ibuprofen is indicated for mild to moderate pain. Other indications include inflammatory diseases and rheumatoid disorders. It is available in oral forms, as well as in an injection form. Onset of action for relieving pain is typically 30 to 60 minutes.

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 cyclic guanosine monophosphate (cGMP) caused by the interaction of acetylcholine and muscarinic receptors on bronchial smooth muscle.

These agents help to reduce mucus in the lungs and relax the smooth muscles of large and medium bronchi. They may be used with short-acting beta₂ -adrenergic bronchodilators.

Ipratropium (Atrovent, Atrovent HFA)

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Ipratropium, which is chemically related to atropine, has antisecretory properties. When applied locally, it inhibits secretions from serous and seromucous glands lining the nasal mucosa.

Class Summary

These agents act by competitively inhibiting histamine at the H1 receptor. This effect mediates bronchial constriction, mucus secretion, smooth muscle contraction, and edema.

Diphenhydramine (Benadryl, Benylin)

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Diphenhydramine is a first-generation antihistamine with anticholinergic effects.

Chlorpheniramine (Chlor-Trimeton)

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Chlorpheniramine is a first-generation agent that competes with histamine or H1-receptor sites on effector cells in blood vessels and the respiratory tract. It is one of the safest antihistamines to use during pregnancy.

Brompheniramine (Bromphen)

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This oral H1 blocker is used for allergic conjunctivitis and rhinitis, angioedema, pruritus, and urticaria. It does not tend to cause drowsiness and is suitable to use on a day-to-day basis.

Class Summary

Several agents (eg, codeine, guaifenesin, dextromethorphan) are intended for the symptomatic relief of cough. However, evidence is mixed regarding the effectiveness of these agents. Cough and cold medicines should be used with caution in children younger than 2 years because serious adverse reactions and fatalities have occurred with over-the-counter preparations. Many over-the-counter cough and cold preparation labels state that the product should not be used in children younger than 4 years.

Guaifenesin and dextromethorphan (Robitussin DM, Mucinex DM, Duratuss DM, Robafen DM, Guaifenex DM)

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This compound treats minor cough resulting from bronchial and throat irritation.

Class Summary

Opioid analgesics bind to opioid receptors in the central nervous system, thus inhibiting pain pathways. In addition, these agents cause cough suppression by direct central action in the medulla.

Codeine

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Codeine is a centrally acting antitussive that also helps to manage the pain of intercostal muscle strain associated with cough.

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, EpiPen, Twinject)

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Epinephrine is used for severe bronchoconstriction, especially with underlying reactive airway disease. Its 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.

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, Dexasone)

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Dexamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Prednisone in equivalent doses may be substituted if administered over the course of 5 days.

Class Summary

These drugs are typically used to relieve nasal symptoms. Decongestants and antihistamines should be used with caution in children younger than 2 years because serious adverse reactions and fatalities have occurred with over-the-counter cough and cold preparations. In 2008, the Consumer Healthcare Products Association modified many over-the-counter cough and cold product labels to state "do not use" in children younger than 4 years.

Pseudoephedrine (Sudafed)

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This agent causes vasoconstriction by directly stimulating alpha-adrenergic receptors in the respiratory mucosa. It is used for symptomatic relief of nasal congestion due to common cold, upper respiratory tract allergies, and sinusitis. It promotes nasal or sinus drainage.

Oxymetazoline (Allerest, Afrin, Dristan, Chlorphed)

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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.

Class Summary

These agents are typically used to relieve nasal symptoms.

Phenylephrine nasal (NeoSynephrine Nasal)

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This agent is a strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity that produces vasoconstriction of arterioles in the body.

Oxymetazoline (Afrin, Dristan 12 Hr Vicks Sinex 12 Hour)

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Oxymetazoline 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.

Questions

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Media Gallery

Seasonal variation of selected upper respiratory tract infection pathogens. PIV is parainfluenza virus, RSV is respiratory syncytial virus, MPV is metapneumovirus, and Group A Strept is group A streptococcal disease.
CT scan of the sinuses demonstrates maxillary sinusitis. The left maxillary sinus is completely opacified (asterisk), and the right has mucosal thickening (arrow). Courtesy of Omar Lababede, MD, Cleveland Clinic Foundation.
Lateral neck radiograph demonstrates epiglottitis. Courtesy of Marilyn Goske, MD, Cleveland Clinic Foundation.
Gonococcal pharyngitis. Image credit: CDC Public Health Image Library (Flumara NJ, Hart G).
Strep throat with petechiae. CDC Public Health Image Library (Eichenwald HF).

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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); itchy throat	Very common	Sometimes
Cough	Sometimes	Common, mild to moderate, hacking cough	Common, dry cough, can be severe
Headache	Sometimes, facial pain	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

Upper Respiratory Tract Infection Medication

Medication Summary

Penicillins, Natural

Class Summary

Penicillin VK (Penicillin V)

Penicillin G benthazine (Bicillin LA, Permapen)

Penicillins, Amino

Class Summary

Ampicillin (Ampi, Omnipen, Penglobe, Principen)

Amoxicillin (Amoxil, Moxatag, Trimox)

Amoxicillin/clavulanate (Augmentin, Augmentin XR, Augmentin ES-600)

Cephalosporins, First Generation

Class Summary

Cefadroxil (Duricef, Ultracef)

Cephalosporins, Second Generation

Class Summary

Cefaclor (Ceclor)

Cefuroxime (Ceftin)

Cephalosporins, Third Generation

Class Summary

Cefotaxime (Claforan)

Macrolides

Class Summary

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

Azithromycin (Zithromax)

Clarithromycin (Biaxin)

Analgesics, Other

Class Summary

Acetaminophen (Tylenol, Feverall, Tempra)

NSAIDs

Class Summary

Naproxen (Aleve, Naprosyn, Naproxen SR, Anaprox)

Ibuprofen (Motrin, NeoProfen, Caldolor, Advil)

Anticholinergics, Respiratory

Class Summary

Ipratropium (Atrovent, Atrovent HFA)

Antihistamines, First Generation

Class Summary

Diphenhydramine (Benadryl, Benylin)

Chlorpheniramine (Chlor-Trimeton)

Brompheniramine (Bromphen)

Antitussives, Non-Narcotic Combos

Class Summary

Guaifenesin and dextromethorphan (Robitussin DM, Mucinex DM, Duratuss DM, Robafen DM, Guaifenex DM)

Antitussives, Opioid Analgesics

Class Summary

Codeine

Alpha/Beta-Adrenergic Agonists

Class Summary

Epinephrine (Adrenalin, EpiPen, Twinject)

Corticosteroids

Class Summary

Dexamethasone (Decadron, Dexasone)

Decongestants, Systemic

Class Summary

Pseudoephedrine (Sudafed)

Oxymetazoline (Allerest, Afrin, Dristan, Chlorphed)

Decongestants, Intranasal

Class Summary

Phenylephrine nasal (NeoSynephrine Nasal)

Oxymetazoline (Afrin, Dristan 12 Hr Vicks Sinex 12 Hour)

References

Tables

Contributor Information and Disclosures

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