Upper respiratory infections involve the nose, sinuses, pharynx, tonsils, and larynx. Acute bronchitis and influenza are included here because they present with similar symptoms and raise the same question: does this client need an antibiotic, an antiviral, or only supportive care?
Key principle: most URIs are viral and self-limited. Antibiotics do not shorten viral illness and cause adverse effects, Clostridioides difficile infection, and resistance. The nurse's roles are supportive care, recognizing the few bacterial or dangerous causes, and prevention.
| Condition | Usual cause | Hallmarks |
|---|
| Common cold (acute rhinitis) | Rhinovirus and other viruses | Sneezing, rhinorrhea, congestion, mild sore throat; low or no fever; lasts 7–10 days |
| Acute pharyngitis / tonsillitis | Mostly viral; group A beta-hemolytic Streptococcus (GAS) in a minority (more often in children 5–15 years) | Sore throat, painful swallowing; GAS suggested by fever, tonsillar exudate, tender anterior cervical nodes, absence of cough |
| Scarlet fever | GAS (toxin) | Sore throat, fever, strawberry tongue, sandpaper-like rash starting on trunk, flushed cheeks with circumoral pallor |
| Infectious mononucleosis | Epstein–Barr virus | Exudative pharyngitis, posterior cervical nodes, fatigue, splenomegaly |
| Acute laryngitis | Viral, voice overuse, irritants | Hoarseness or loss of voice, dry cough |
| Acute bronchitis | Viral in most cases | Cough (with or without sputum) lasting up to about 3 weeks; no signs of pneumonia |
| Influenza | Influenza A or B | Abrupt fever, myalgia, headache, malaise, dry cough |
Transmission is by respiratory droplets, aerosols, and contaminated hands and surfaces — which is why hand hygiene and cough etiquette are the foundation of prevention.
Subjective
- Sore throat, painful swallowing, nasal congestion, cough, hoarseness
- Onset (gradual in colds, abrupt in influenza), duration, sick contacts
- Fever, chills, myalgia, fatigue
- Risk factors for complications: age 65 years or older, pregnancy, chronic lung or heart disease, diabetes, immunosuppression, residence in long-term care
Objective
- Temperature, respiratory rate, SpO₂
- Pharynx: erythema, tonsillar exudate, palatal petechiae; uvula position
- Cervical lymph nodes (tender anterior nodes favor GAS)
- Lung sounds — clear in URI and bronchitis; crackles, bronchial breath sounds, or hypoxemia suggest pneumonia
- Hydration status: mucous membranes, urine output, intake
Clinical scores for sore throat. The Centor (McIsaac) criteria give 1 point each for fever, tonsillar exudate or swelling, tender anterior cervical nodes, and absence of cough (with an age adjustment). Low scores make GAS unlikely; higher scores support testing — not empiric antibiotics.
| Test | Use |
|---|
| Rapid antigen detection test (RADT) for GAS | First test for suspected strep pharyngitis; quick result guides antibiotic decision |
| Throat culture | Back-up for a negative RADT in children and adolescents; usually not needed in adults because post-streptococcal complications are rare |
| Rapid influenza or molecular (PCR) respiratory panel | Confirms influenza, COVID-19, RSV when it will change management; do not delay antivirals for high-risk clients while waiting |
| Monospot / EBV serology | Suspected mononucleosis |
| Chest X-ray | Only if pneumonia is suspected (abnormal vital signs, abnormal lung exam, hypoxemia) — not routine for acute bronchitis |
Throat swab technique: swab both tonsils and the posterior pharynx without touching the tongue, cheeks, or teeth.
Supportive care (all viral URIs)
- Rest, fluids, humidified air, saline nasal spray, warm saline gargles, throat lozenges (older children and adults)
- Antipyretic/analgesic: acetaminophen or an NSAID
- Cough in acute bronchitis: antitussive (e.g., dextromethorphan) may be used for a dry, bothersome cough; do not suppress a productive cough that clears secretions
- Antibiotics are not indicated for colds, viral pharyngitis, laryngitis, or acute bronchitis. Purulent (colored) sputum alone is not a reason to start antibiotics in acute bronchitis
Streptococcal pharyngitis (confirmed by RADT or culture)
- Penicillin V or amoxicillin for 10 days; a single IM dose of benzathine penicillin G if adherence is a concern
- Penicillin allergy: cephalexin (if not anaphylactic), clindamycin, or azithromycin (resistance possible)
- Purpose: shorten symptoms, reduce spread, and prevent acute rheumatic fever and suppurative complications
- Client is considered no longer contagious after about 12–24 hours of effective antibiotic therapy and once fever-free
Influenza
- Antiviral treatment as soon as possible for clients who are hospitalized, severely ill, or at higher risk of complications — best within 48 hours of symptom onset, but still given later to hospitalized or high-risk clients
- Oseltamivir (oral) is preferred for hospitalized clients and in pregnancy; other options include inhaled zanamivir, IV peramivir, and single-dose oral baloxavir (ages 5 years and older)
- Healthy outpatients may be treated if therapy can start within 48 hours
Drug safety
| Drug | Key safety points |
|---|
| Acetaminophen | Hepatotoxicity — assess liver disease and alcohol use; usual adult maximum 4 g/day (lower limits, often 2–3 g/day, for liver disease, heavy alcohol use, or low body weight). Check combination cold products for hidden acetaminophen |
| NSAIDs (ibuprofen) | GI bleeding, kidney injury, fluid retention; avoid in kidney disease, active ulcer, late pregnancy, and aspirin-sensitive asthma |
| Aspirin | Avoid in children and teenagers with viral illness — risk of Reye syndrome |
| Penicillins / amoxicillin | Ask about allergy before the first dose; watch for rash, anaphylaxis, diarrhea. Amoxicillin often causes a rash in mononucleosis |
| Oral decongestants (pseudoephedrine) | Raise BP and heart rate, insomnia; caution in hypertension, heart disease, glaucoma, hyperthyroidism, prostatic hyperplasia; do not combine with MAO inhibitors |
| First-generation antihistamines (diphenhydramine) | Sedation, anticholinergic effects; fall risk in older adults |
| Oseltamivir | Nausea and vomiting (take with food); rare neuropsychiatric events; reduce dose when creatinine clearance is 60 mL/min or less |
| Zanamivir | Inhaled — not recommended with asthma or COPD (bronchospasm) |
| Baloxavir | Not recommended in pregnancy or severe immunosuppression; avoid taking with dairy, calcium, or antacids |
| Dextromethorphan | Serotonin syndrome risk with SSRIs/MAO inhibitors; misuse potential |
Over-the-counter cough and cold products should not be given to children under 2 years (FDA) and are labeled not for use under 4 years; they offer little benefit in older children.
Tonsillectomy is considered for recurrent severe tonsillitis, peritonsillar abscess, or obstructive sleep-disordered breathing.
Listed in priority order.
- Airway
- Identify red flags of airway compromise: drooling, muffled "hot potato" voice, stridor, trismus, inability to swallow, tripod positioning (possible epiglottitis or peritonsillar/deep neck abscess). Keep the client upright and calm, do not examine the throat with a tongue blade if epiglottitis is suspected, and call for airway support
- Breathing and oxygenation
- Monitor respiratory rate and SpO₂; assess lung sounds for signs of pneumonia
- Infection control
- Standard plus droplet precautions for influenza; follow facility policy for COVID-19 and other respiratory viruses
- Mask the symptomatic client during transport; hand hygiene before and after contact
- Medication administration
- Obtain culture or RADT before the first antibiotic dose when ordered
- Before giving acetaminophen, check liver function history and total daily dose from all sources
- Start influenza antivirals promptly in high-risk clients
- Hydration and comfort
- Encourage fluids (2–3 L/day unless restricted), humidified air, warm saline gargles, soft cool foods
- Laryngitis: voice rest (avoid whispering, which also strains the cords), humidification, avoid caffeine and alcohol, no smoking
- Post-tonsillectomy care
- Position side-lying or semi-Fowler's; watch for frequent swallowing, vomiting bright red blood, and rising pulse — signs of hemorrhage
- Ice collar; cool fluids; no straws, avoid red-colored drinks, avoid vigorous coughing or throat clearing
- Bleeding risk is highest in the first 24 hours and again around 5–10 days when the scabs separate
- Hand hygiene (soap and water at least 20 seconds, or alcohol-based rub) and cough etiquette — cover coughs with a tissue or elbow, discard tissues, wear a mask when sick
- Stay home while febrile; return to work or school when fever-free for about 24 hours without antipyretics, or per local guidance
- Complete the full antibiotic course for strep throat even when feeling better; replace the toothbrush after 24 hours of therapy
- Antibiotics do not treat colds, most sore throats, or acute bronchitis; a cough may last up to 3 weeks
- Annual influenza vaccination for everyone 6 months and older; stay up to date with COVID-19 and other recommended vaccines
- Read labels to avoid duplicate acetaminophen; do not give aspirin to children or teenagers
- Mononucleosis: avoid contact sports and heavy lifting until cleared (risk of splenic rupture)
- Seek care for: difficulty breathing or swallowing, drooling, high fever lasting more than 3 days, symptoms that improve and then worsen, chest pain, confusion, or signs of dehydration
| Complication | What to watch for |
|---|
| Peritonsillar abscess | Severe one-sided throat pain, trismus, muffled voice, uvula deviated away from the affected side |
| Epiglottitis | Sudden high fever, drooling, stridor, tripod position — airway emergency |
| Acute rheumatic fever (after untreated GAS) | Carditis, migratory polyarthritis, chorea, subcutaneous nodules, erythema marginatum 2–4 weeks after pharyngitis |
| Post-streptococcal glomerulonephritis | Dark (cola-colored) urine, edema, hypertension; not prevented by antibiotics |
| Secondary bacterial pneumonia (after influenza) | Worsening after initial improvement, high fever, productive cough, hypoxemia |
| Sinusitis, otitis media | Facial pain, ear pain, persistent purulent discharge |
| Splenic rupture (mononucleosis) | Sudden left upper quadrant pain, shock |
- Most URIs, sore throats, and acute bronchitis are viral — no antibiotics
- Antibiotics for pharyngitis only when GAS is confirmed (RADT or culture)
- RADT first; back up a negative RADT with a culture in children and adolescents
- Strep treatment: penicillin or amoxicillin for 10 days to prevent rheumatic fever
- Scarlet fever = GAS + strawberry tongue + sandpaper rash
- Influenza: start antivirals within 48 hours — and as soon as possible regardless of timing for hospitalized or high-risk clients; oseltamivir is preferred in pregnancy
- Acetaminophen: check liver disease and total daily dose (hepatotoxicity)
- Zanamivir is not for clients with asthma or COPD
- Colored sputum alone does not mean bacterial bronchitis
- Airway red flags: drooling, muffled voice, stridor, trismus
- Prevention: hand hygiene, cough etiquette, vaccination
- Post-tonsillectomy: frequent swallowing = bleeding; no straws
Country Notes
United States
- Annual influenza vaccination is recommended for everyone 6 months and older, following the CDC immunization schedules.
- Many urgent care and retail clinics perform point-of-care RADT and influenza/COVID-19 testing; antibiotic stewardship programs track antibiotic use for URIs.
Philippines
- Antibiotics are sometimes obtained without a prescription; teach clients that colds and most sore throats do not need antibiotics and that incomplete courses promote resistance.
- Rheumatic heart disease remains a concern in low- and middle-income settings, making full treatment of confirmed strep pharyngitis especially important.
- Influenza circulates for much of the year in tropical climates, often peaking in the rainy season; timing of vaccination may follow local health authority advice.