Acute Respiratory Infections

My approach follows current evidence-based clinical guidelines, including recommendations from the Centers for Disease Control and Prevention (CDC), the American Academy of Family Physicians (AAFP), and other professional medical organizations. 

Please visit the CDC website to view their treatment recommendations for respiratory infections:
https://www.cdc.gov/antibiotic-use/hcp/clinical-care/adult-outpatient.html
 

Most Respiratory Illnesses Are Viral
 

The majority of acute respiratory illnesses—including the common cold, bronchitis, sinus infections, Flu, COVID-19, and sore throat—are caused by viruses. Antibiotics are ineffective against viruses, and many bacteria have gained resistance from common antibiotics.

Using antibiotics may lead to unecessary side effects including diarrhea, dehydration, nausea, allergic reactions, Clostridioides difficile (C. diff) gastrointestinal infection, and antibiotic resistance.

There are certain medicines for viral infections. However, for most healthy individuals without concerning symptoms or examination findings, the best treatment is supportive care, which may include:
 

• Rest

• Staying properly hydrated

• Practicing good hygiene (hand washing, social distancing, etc.)- helps reduce spread of infection

• Flutter device - helps mobilize secretions in the airways

• Nasal saline drop instillation w/ bulb suction- for young children to help remove nasal secretions

• Acetaminophen (Tylenol) or Ibuprofen (Advil, Motrin) for fever, body aches, or pain.

• Decongestants - constrict swollen blood vessels in the nasal passages to relieve nasal congestion. Do not use in young children.
  - Oral Phenylephrine (Over-the-Counter): The FDA concluded that oral phenylephrine is ineffective and no better than a placebo for relieving nasal congestion, as very little active medication reaches the bloodstream when swallowed.
  - Oral Pseudoephedrine: Because it acts as a systemic stimulant, it should be used with caution—or avoided—in patients with uncontrolled high blood pressure, heart disease, thyroid disorders, or prostatic hypertrophy.
  - Nasal Sprays (e.g., Oxymetazoline / Afrin): Provide rapid, localized relief. These sprays must not be used for more than 3 to 5 consecutive days to avoid dependence on the medication and rebound congestion (rhinitis medicamentosa).

-Be extra cautious about not exceeding the max dose for acetaminophen, as overdose can cause liver failure and death. It is commonly found in many different over-the-counter products.

-Seek emergency care before giving acetaminophen to children under 3 months of age, as rectal fevers of 100.4 F and higher require immediate evaluation in this age group. 

-Aspirin should not be given to children or teenagers with viral illnesses because of the risk of a rare but dangerous condition called Reye's syndrome.

-Do not give Ibuprofen to children under 6 months old due to possible harmful effects. 

-Do not give honey to children under 1 year old due to increased risk for bacterial botulism. 

-Do not give over-the-counter cold/cough medicines (e.g., dextromethorphan, decongestants - like pseudoephedrine, antihistamines like Benadryl, oral anesthetics- like benzocaine or lidocaine) to young children, especially to those under 2 years of age. 

Secondary Bacterial Infections
 

Most viral respiratory illnesses improve on their own. Occasionally, however, a secondary bacterial infection can develop, particularly in older adults, people with weakened immune systems, or those with other medical conditions.

One important warning sign is called "double worsening." This occurs when symptoms begin improving, but then suddenly worsen and become severe--such as having high fever.

If this pattern occurs, you should be re-evaluated, as it may indicate that a secondary bacterial infection has developed. However, secondary bacterial infections are not the only cause of double worsening, and multiple factors need to be considered.  

Special Considerations for Patients With COPD
 

Respiratory illnesses in patients with chronic obstructive pulmonary disease (COPD) may require a different approach. Depending on symptoms and examination findings, treatment may include bronchodilators, corticosteroids, and, in some cases, antibiotics. Antibiotics may be considered during certain COPD exacerbations when bacterial infection is suspected, such as when patients have increased shortness of breath, increased sputum production, and increased sputum purulence (the Anthonisen criteria).

Special Considerations for Patients With Asthma

For patients with asthma or airway reactive disease, steroids and bronchodilators may be utilized. 

Treatment decisions are individualized based on the patient's overall condition and risk factors.
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Acute Rhinosinusitis (Sinus Infection)
 

Most sinus infections are caused by viruses.  

Current CDC evidence-based guidelines recommend considering antibiotics when one or more of the following criteria are met:
 

• Symptoms persist for 10 days or longer without improvement

• Severe symptoms occur for at least 3 consecutive days, including a fever of 102°F (39°C) or higher AND purulent nasal discharge or severe facial pain.

• Double worsening: Symptoms initially improve after day 5-6, but then they suddenly worsen for 3-4 days with new or worsening fever, facial pain, daytime cough, or increased nasal discharge after what appeared to be a typical viral upper respiratory infection.

*The IDSA (Infectious Diseases Society of America) & American Academy of Family Physicians (AAFP) do not mention a certain number of days required to satisfy the criteria for double worsening. However, the 3-4 days recommended by the CDC is best for most patients without severe symptoms due to the fact that there can be biphasic viral infections, sequential viral infections, and post-infectious inflammatory responses. 

Viral rhinosinusitis has a very small chance of turning bacterial, but certain factors can increase these chances: impaired immunity, structural blockages, impaired mucociliary function, and other inflammatory causes. These factors are often caused by smoking, COPD, asthma, IgA deficiency, cystic fibrosis, primary ciliary dyskinesia, allergic rhinitis, GERD, deviated septum, and polyps. 

Strep Throat
 

Unlike most sore throats, strep throat is caused by Group A Streptococcus Pyrogenes, a bacterial infection that should be treated with antibiotics.

Appropriate treatment can shorten symptom duration, reduce transmission to others, and lower the risk of complications such as acute rheumatic fever. People with strep throat are generally considered no longer contagious after approximately 24 hours of appropriate antibiotic therapy.
 

Healthcare providers commonly use the Modified Centor Score to help determine whether strep throat testing or treatment is appropriate. 

Points are assigned for:

• Tonsillar swelling or white exudate (pus): +1

• Tender lymph nodes in the front of the neck: +1

• Fever of 100.4°F (38°C) or higher: +1

• Absence of a cough: +1

Age adjustment:

• Ages 3–14 years: +1 point

• Ages 15–44 years: 0 points

• Ages 45 years and older: -1 point

*Group A strep throat is uncommon in children younger than 3 years old.

Laryngotracheobronchitis (Croup)
 

Croup is usually caused by a virus. It is a common upper respiratory infection that primarily affects young children. 

Symptoms often begin like a common cold (runny or stuffy nose, sore throat, low-grade fever). As time progresses, many children develop the classic "barking" cough, hoarseness, and stridor, a high-pitched sound heard when breathing in. Symptoms are often worse at night.

Most cases are diagnosed based on the child's symptoms and physical examination.

Treatment focuses on supportive care, including maintaining hydration, controlling fever when appropriate, and monitoring breathing. Corticosteroids are commonly prescribed because they reduce upper airway inflammation and improve symptoms.

Influenza (Flu)

Flu is one specific respiratory disease caused by Influenza viruses. Symptoms can range from mild to severe and may lead to complications such as pneumonia or worsening of underlying conditions.

Treatment typically consists of supportive care. However, antiviral medications for the Flu such as Tamiflu may be available in certain situations. Tamiflu is an oral capsule or suspension antiviral indicated for patients 2 weeks of age and older who have been symptomatic for no more than 48 hours. Tamiflu reduces the duration of flu symptoms by roughly 1 to 1.5 days and reduces the risk of complications in high risk patients. It can be prescribed to healthy patients within the 48-hour window if symptom reduction is desired, though treatment is prioritized and recommended for high-risk groups. It can also be utilized for post-exposure prophylaxis in high-risk individuals aged 1 year and older. 

People with Flu should stay home and away from others while they are experiencing fever or worsening symptoms. They may return to normal activities once symptoms have been improving for at least 24 hours and they have been fever-free for at least 24 hours without fever-reducing medication. For the next 5 days, additional precautions such as masking, improving ventilation, and avoiding high-risk individuals are recommended because some people may still spread the virus.
Treatment typically consists of supportive care. However, antiviral medications may be available in certain situations. 

COVID-19

COVID-19 is a respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Symptoms can range from mild to severe and may lead to complications such as pneumonia or worsening of underlying conditions.

Treatment typically consists of supportive care. However, antiviral medications such as Paxlovid may be available for people with high risk for complications. Paxlovid is an oral COVID-19 antiviral approved or authorized for adults and pediatric patients aged 12 years and older weighing at least 88 pounds with mild to moderate symptoms WITH at least one major risk factor for progression to severe illness (e.g., age 65+, pregnant individuals, immunosuppression, diabetes, chronic lung or kidney disease, cardiovascular disease, obesity) AND it must be initiated within 5 days of the onset of first symptoms. It has significant drug-drug interactions. 

People with COVID-19 should stay home and away from others while they are experiencing fever or worsening symptoms. They may return to normal activities once symptoms have been improving for at least 24 hours and they have been fever-free for at least 24 hours without fever-reducing medication. For the next 5 days, additional precautions such as masking, improving ventilation, and avoiding high-risk individuals are recommended because some people may still spread the virus.

Bronchiolitis
 

Bronchiolitis is usually caused by RSV or another virus. It primarily affects infants and young children. Symptoms usually begin with common cold symptoms (runny nose, congestion, cough, mild fever) and progresses to inflammation and mucus buildup in the the small airways of the lungs. 

Diagnosis is usually based on the child's history, physical examination, and sometimes lab results. 

Treatment is typically supportive care: frequent small feedings of breast milk, formula, or oral rehydration solutions to maintain hydration; saline nasal drops with suction with a bulb syringe; rest; and fever-reducing medications.

Epiglottitis

Epiglottitis is a mostly caused by a bacterial infection (mostly from Haemophilus influenzae type b in unvaccinated or immunocompromised children and from several different bacterial types in adults). It is a serious bacterial infection that causes rapid swelling of the epiglottis, the flap that covers the airway during swallowing.
 

Symptoms typically develop rapidly and include severe sore throat, painful or difficult swallowing, drooling, muffled voice, fever, stridor, and difficulty breathing. Many patients sit leaning forward in the tripod position to breathe easier. 
 

Diagnosis and treatment should occur in the emergency department, where the airway can be closely monitored and protected if necessary.
 

Treatment typically includes emergency care with intravenous antibiotics and corticosteroids to reduce airway swelling. Call 911 or seek emergency medical care immediately if epiglottitis is suspected. Do not attempt to examine the throat at home or force the person to lie down, as this can worsen airway obstruction.
 

Pertussis (Whooping Cough)
 

Pertussis is caused by the bacteria Bordetella Pertussis. Pertussis is a highly contagious bacterial respiratory infection that most commonly affects individuals who are unvaccinated or immunocompromised.
 

The illness begins with the catarrhal stage, which lasts approximately one to two weeks and resembles a common cold. It then progresses to the paroxysmal stage, lasting two to six weeks or longer, during which patients develop extreme coughing fits and then a high-pitched "whoop" during inhalation. Finally, patients enter the convalescent stage, during which coughing gradually improves over several weeks to months.

Diagnosis may involve a nasal swab for PCR testing or bacterial culture, particularly during the early stages of illness.
 

Treatment for mild to moderate cases includes antibiotics and supportive care. People are generally considered no longer contagious after completing 5 days of appropriate antibiotic therapy.

Pharyngitis (Sore Throat)

Pharyngitis is mainly caused by a virus. Viral pharyngitis is often part of the common cold, which usually presents with cough, congestion, runny nose, and mild fever. Viral infections are typically managed with rest, fluids, pain relievers, throat lozenges, and warm saltwater gargles. Flu, Mono, and COVID are other viral causes of pharyngitis, but they tend to have much more severe and systemic effects. 

Some cases of pharyngitis are bacterial, mostly by Group A Streptococcus (strep throat), a bacterial infection that requires treatment with antibiotics [see strep throat section]. One complication of bacterial cases are peritonsillar abscesses. This is a bacterial infection that forms a pocket of pus next to a tonsil, usually as a complication of bacterial tonsillitis. Symptoms include severe one-sided throat pain, difficulty swallowing, muffled voice, drooling, difficulty opening the mouth (trismus), swelling of one tonsil, and deviation of the uvula away from the affected side. A peritonsillar abscess requires prompt evaluation for drainage and antibiotic treatment by a specialist.

Infectious Mononucleosis (Mono)
 

Mono is most commonly caused by the Epstein-Barr virus (EBV). Some respiratory symptoms, particularly a severe sore throat with significant fatigue and swollen posteior lymph nodes may suggest mono rather than a typical viral upper respiratory infection. Symptoms include:
 

• Significant fatigue

• Fever

• Sore throat

• Swollen, tender lymph nodes toward the side/back of neck

• Enlarged tonsils, sometimes with white patches

• Body aches

• An enlarged spleen

Patients with mono who are inappropriately treated with antibiotics, such as amoxicillin or ampicillin, can end up with a rash. This may lead to an erroneous allergic reaction being listed on your record. 

One important consideration with mono is spleen enlargement. Although rare, an enlarged spleen can rupture, which is a medical emergency. For this reason, individuals diagnosed with mono are often advised to avoid contact sports and heavy lifting for at least 3-4 weeks and until they feel better. 

Seek urgent medical attention if you develop symptoms that could suggest a splenic injury, such as:

• Sudden severe abdominal pain, especially in the upper left abdomen

• Left shoulder pain

• Dizziness, fainting, or feeling unusually weak

A careful history, physical examination, and certain lab testing can help distinguish mono from other causes of sore throat and respiratory symptoms.
 

Pneumonia
 

Pneumonia is an infection and inflammation of the lungs that affects the air sacs (alveoli), causing them to fill with fluid and mucus. This can interfere with normal oxygen exchange and make breathing more difficult.

Pneumonia can be caused by a variety of infectious organisms, including bacteria, viruses, and fungi. Common causes include Streptococcus pneumoniae (a frequent cause of bacterial community-aqcuired pneumonia), Flu, COVID-19, RSV, and other respiratory pathogens.

Symptoms of pneumonia can vary depending on the cause and severity of illness but may include:
 

• Cough (with or without mucus production)

• Fever and chills

• Shortness of breath

• Chest pain that worsens with deep breathing or coughing

• Fatigue and weakness

• Rapid breathing or increased work of breathing

• Confusion, especially in older adults

Some bacterial causes of pneumonia are considered "atypical" because they often develop more gradually and cause a persistent dry cough, fatigue, headache, body aches, and fewer obvious early exam findings. Common causes include Mycoplasma pneumoniae and Chlamydia pneumoniae, which are more frequently seen in children and young adults. Legionnaires' disease is another form of atypical pneumonia caused by Legionella pneumophila. It is more likely to occur in older adults, people with chronic medical conditions, and individuals with weakened immune systems. Legionella is associated with exposure to contaminated water sources that produce aerosolized water droplets, such as large building water systems, hospitals, nursing homes, hotels, cooling towers, and hot tubs. It can cause severe illness. 

Pneumonia may develop as a primary infection or as a complication of another respiratory illness. For example, influenza and COVID-19 can directly cause viral pneumonia or weaken the respiratory tract and increase the risk of secondary bacterial pneumonia.

Diagnosis is based on a combination of symptoms, physical examination findings, and, when appropriate, additional testing such as a chest X-ray, oxygen measurement, blood tests, or respiratory infectious testing. 

Treatment depends on the cause and severity of illness. Bacterial pneumonia is treated with antibiotics, while viral pneumonia is typically managed with supportive care, although certain viral infections may have specific antiviral treatments. Supportive care may include rest, fluids, fever control, and monitoring oxygen levels. More severe cases may require hospitalization, oxygen therapy, intravenous medications, or respiratory support.

People at higher risk for severe pneumonia include:
 

• Infants and young children

• Older adults

• Individuals with chronic lung disease, heart disease, diabetes, kidney disease, or weakened immune systems

• People who are pregnant or immunocompromised

Vaccination can reduce the risk of certain causes of pneumonia, including influenza, COVID-19, and pneumococcal disease.
                                      
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                                            GENERAL MEDICAL ADVICE
If one develops severe shortness of breath, chest pain, confusion, bluish lips or face, signs of severe dehydration, or other emergency symptoms, seek immediate medical attention. 

Infants younger than 3 months with a rectal temperature of 100.4°F (38.0°C) or higher should be taken to the nearest emergency department immediately.
 

Disclaimer: The information provided on this page is intended for educational purposes only and summarizes current evidence-based clinical guidelines. This information does not replace an individualized medical evaluation. Every patient is different and not everyone will present with the same symptoms. Age, medical history, chronic health conditions, medications, physical examination findings, and the overall clinical picture all influence diagnosis and treatment recommendations. If you have concerning or worsening symptoms, seek medical evaluation promptly. If you are experiencing a medical emergency, call 911 or go to the nearest emergency department.

 

                                               References & Guidelines

• Centers for Disease Control and Prevention (CDC)

• American Academy of Family Physicians (AAFP)

• Infectious Diseases Society of America (IDSA)

• American Academy of Pediatrics (AAP)

• American Thoracic Society (ATS)

• American College of Physicians (ACP)

• U.S. Food and Drug Administration (FDA)