Key Facts

URTIs encompass the common cold (acute nasopharyngitis), pharyngitis, tonsillitis, acute rhinosinusitis, and acute otitis media. They are overwhelmingly viral and self-limiting, making antimicrobial stewardship a key management principle.

Epidemiology

• Adults average 2-4 URTIs per year; children 6-8 per year
• Peak incidence in autumn and winter months
• Account for approximately 60% of all antibiotic prescriptions in UK primary care
• Group A Streptococcus (GAS) causes only 5-15% of adult pharyngitis

Aetiology

• Viral (>90%): rhinovirus (30-50%), coronavirus (10-15%), influenza A and B, parainfluenza, RSV, adenovirus, EBV
• Bacterial (<10%): Group A Streptococcus (pharyngitis/tonsillitis), Streptococcus pneumoniae, Haemophilus influenzae (sinusitis), Moraxella catarrhalis
• Fungal: rare; consider in immunosuppressed (oropharyngeal candidiasis)

Pathophysiology

• Viral entry through respiratory epithelium via nasal or conjunctival mucosa
• Incubation period typically 1-3 days
• Local inflammatory response with mucosal oedema, increased mucus production, and vascular engorgement
• Cytokine release (IL-1, IL-6, TNF-α, interferons) mediates systemic symptoms
• Bacterial superinfection may complicate viral URTI, particularly rhinosinusitis

Common Cold

• Nasal congestion and rhinorrhoea (initially clear, may become mucopurulent)
• Sore throat (usually mild)
• Sneezing, mild malaise
• Low-grade fever
• Duration: typically 7-10 days

Acute Pharyngitis/Tonsillitis

• Sore throat (predominant symptom)
• Odynophagia (painful swallowing)
• Tonsillar enlargement ± exudate
• Cervical lymphadenopathy
• Fever

Acute Rhinosinusitis

• Nasal congestion and purulent nasal discharge
• Facial pain/pressure (worse on bending forward)
• Reduced sense of smell
• Duration: symptoms >10 days or worsening after initial improvement suggest bacterial component

Red Flags

• Trismus, unilateral swelling, uvular deviation — peritonsillar abscess (quinsy)
• Stridor or drooling — epiglottitis or airway compromise
• Persistent unilateral symptoms >3 weeks — consider nasopharyngeal malignancy
• Systemically unwell (high fever, rigors, inability to swallow) — consider hospital admission
• Recurrent tonsillitis meeting Paradise criteria — ENT referral for tonsillectomy

Bedside

• Observations: temperature, HR, RR, oxygen saturations
• Throat examination with tongue depressor
• Centor score or FeverPAIN score for sore throat

Bloods

• Not routinely required for uncomplicated URTI
• FBC and monospot test if glandular fever suspected
• CRP point-of-care testing may guide antibiotic decisions (NICE NG120)

Microbiology

• Throat swab for culture: not routinely recommended; consider if recurrent tonsillitis, treatment failure, or outbreak setting
• Rapid antigen detection test (RADT) for GAS: not widely used in UK primary care but high specificity

Imaging

• Not required for uncomplicated URTI
• CT sinuses if complicated sinusitis suspected (orbital/intracranial extension)
• Lateral neck X-ray if epiglottitis suspected (thumb sign)

Special Tests

• FeverPAIN/Centor scores to risk-stratify sore throat for antibiotic need
• CRP point-of-care testing (NICE NG120): CRP <20 mg/L supports no antibiotics; CRP 20-100 mg/L supports delayed antibiotics; CRP >100 mg/L supports immediate antibiotics

Non-pharmacological

• Reassurance: explain viral aetiology and expected time course
• Adequate fluid intake and rest
• Honey and lemon in warm water for sore throat (evidence for honey in cough in children >1 year)
• Saline nasal irrigation for rhinosinusitis
• Steam inhalation (limited evidence but widely used)
• Provide safety-netting advice and expected illness duration

Pharmacological

Symptomatic relief:

• Paracetamol 1g QDS or ibuprofen 400mg TDS for pain and fever
• Nasal decongestants: xylometazoline 0.1% spray (max 7 days) for congestion
• Throat lozenges/sprays for local analgesia

Antibiotics for sore throat (NICE NG84):

• No antibiotic: FeverPAIN 0-1 or Centor 0-1
• Delayed antibiotic (back-up prescription): FeverPAIN 2-3 or Centor 2-3
• Immediate antibiotic: FeverPAIN 4-5 or Centor 3-4
• First-line: phenoxymethylpenicillin 500mg QDS for 5-10 days
• Penicillin allergy: clarithromycin 250-500mg BD for 5 days

Antibiotics for acute rhinosinusitis (NICE NG79):

• Most cases do not require antibiotics (symptom duration >10 days or worsening after initial improvement)
• First-line: phenoxymethylpenicillin 500mg QDS for 5 days
• Alternative: doxycycline 200mg on day 1 then 100mg OD for 5 days; or clarithromycin 500mg BD for 5 days

Surgical

• Tonsillectomy: consider if Paradise criteria met (≥7 episodes in 1 year, ≥5/year for 2 years, or ≥3/year for 3 years)
• Incision and drainage for peritonsillar abscess

Referral Criteria

• Peritonsillar abscess: same-day ENT referral
• Epiglottitis: emergency admission
• Recurrent tonsillitis meeting criteria: ENT referral
• Persistent unilateral nasal symptoms: 2-week-wait ENT referral (exclude malignancy)

• Common cold: resolves in 7-10 days; cough may persist for 3-4 weeks
• Bacterial tonsillitis: symptom resolution in 3-4 days with antibiotics; without antibiotics, 85% resolve within 7 days
• Acute rhinosinusitis: 80% resolve within 2-3 weeks without antibiotics
• Complications: peritonsillar abscess in <1% of sore throat cases; post-streptococcal complications (rheumatic fever, glomerulonephritis) very rare in UK
• Antibiotic prescription reduces sore throat duration by approximately 16 hours (NNT 6 to prevent 1 sore throat at day 3)

FeverPAIN Score

Centor Criteria