Adult with acute upper respiratory symptoms
Sore throat, blocked or runny nose, facial pain or acute cough. Adults 18 years and over who are not immunocompromised.
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Family MedicineManagement
Upper Respiratory Infection Management (IDSA/CDC)
Upper Respiratory Infection Management (IDSA/CDC): Adult with acute upper respiratory symptoms → Red flags first: any one = ED or same-day review → Main...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Warning Red flags first: any one = ED or same-day review
Check before you treat as a simple infection. This pathway is not for children, immunocompromised patients, or asthma or COPD flares.
- Airway or deep neck: stridor, drooling, cannot swallow, muffled voice, trismus, one-sided tonsil or neck swelling, toxic look
- Eye or brain: eyelid swelling or redness, double vision, reduced vision, severe headache, confusion, stiff neck, focal signs
- Sepsis or hard to breathe: very unwell, breathless, low SpO2, confusion
03Decision Main syndrome?
Common cold, sore throat, nose and sinus symptoms, or cough.
- Common cold
04Action All syndromes, including common cold: symptom relief
No antibiotic for the common cold. Every patient gets this care and the safety-net advice.
- Paracetamol or ibuprofen for pain or fever
- Ibuprofen: avoid in kidney disease, peptic ulcer, heart failure, pregnancy, NSAID-sensitive asthma, or with an anticoagulant
- Decongestant: nasal spray 3 days at most; avoid pseudoephedrine in pregnancy, uncontrolled high BP or with an MAOI
- Honey, lozenges and saline nasal spray or rinse may help
05Action Safety-net advice for every patient
Tell the patient when to come back.
- Hard to breathe, noisy breathing, drooling or cannot swallow: call 000 (Australia) or go to ED
- Eye swelling or redness, vision change, severe headache, confusion or stiff neck: ED now
- Worse quickly, or very unwell: same-day review
- Not better: sore throat after 1 week, sinus symptoms after 3 weeks, cough after 3 to 4 weeks
- Sore throat
06Decision Sore throat: high risk of acute rheumatic fever?
High risk: Aboriginal and Torres Strait Islander people in rural or remote areas; Aboriginal and Torres Strait Islander, Maori or Pacific people in crowded or low-income households; ARF-endemic setting; past ARF or RHD and under 40 years; recent ARF or RHD in the family or household. Urban First Nations, Maori and Pacific people and migrants from high-burden countries may also be high risk: if unsure, treat as high risk.
- If Yes
07Action High ARF risk: swab and give antibiotic the same day
Do not rely on the Centor score or a negative rapid test. Adult doses.
- Take a throat swab, then treat at once
- Preferred: benzathine benzylpenicillin G 1,200,000 units IM, single dose
- Oral if IM not possible (anticoagulant, bleeding disorder, declines): phenoxymethylpenicillin 500 mg 12-hourly for 10 days
- Non-severe penicillin allergy: cefalexin 1 g 12-hourly for 10 days
- Immediate penicillin allergy: azithromycin 500 mg daily for 5 days
- Joint pain, chest pain, breathlessness or chorea: assess for ARF
- Path rejoins step 04Shared downstream outcome
If No08Action Sore throat, not high ARF risk: Centor score
One point each. Treat only if strep A is confirmed.
- Fever, tonsillar exudate, tender anterior neck nodes, no cough
- Score 0 or 1: no test and no antibiotic
- Score 2 or more: rapid strep A antigen test or throat swab
- Adults: a negative rapid test needs no back-up culture
09Decision Strep A test positive?
Score 0 or 1 (not tested) counts as No.
- If Yes
10Action Strep A positive: antibiotic for 10 days
Penicillin is first choice. Adult doses.
- Phenoxymethylpenicillin (penicillin V) 500 mg orally 12-hourly for 10 days
- Or amoxicillin 500 mg 12-hourly or 1 g daily for 10 days; avoid if glandular fever is possible (rash)
- Non-severe penicillin allergy: cefalexin 500 mg to 1 g 12-hourly for 10 days
- Immediate penicillin allergy: azithromycin 500 mg daily for 5 days, or clindamycin 300 mg 8-hourly for 10 days
- Path rejoins step 04Shared downstream outcome
If No11Action Strep A negative or not tested (not high ARF risk): no antibiotic
Most sore throats are viral and last about 1 week. Give symptom relief and safety-net advice.
- Path rejoins step 04Shared downstream outcome
- Nose and sinus
12Action Nose and sinus symptoms: viral or bacterial?
Most are viral and last 2 to 3 weeks.
- Bacterial more likely if: symptoms over 10 days without improvement
- Or severe onset: fever 39 °C or higher with purulent discharge or facial pain for 3 to 4 days
- Or double worsening: worse again after first getting better
- Tooth pain or swelling: think of a dental cause
13Decision Bacterial sinusitis criteria met?
Any one of: over 10 days, severe onset, double worsening.
- If Yes
14Action Criteria met, not very unwell: watchful waiting first
Antibiotics make little difference to how long symptoms last.
- Offer no antibiotic or a back-up (delayed) prescription
- Use the back-up script if not better in 7 days, or worse at any time
- Consider a nasal corticosteroid spray for 14 days
- Very unwell or high risk of complications: give antibiotic now (next step)
15Action Antibiotic needed (very unwell, worse, or not better by day 7): 5 days
Adult doses. Pregnancy: do not use doxycycline.
- First choice: amoxicillin 500 mg orally 8-hourly for 5 days
- Very unwell, high risk of complications or recent antibiotic: amoxicillin-clavulanate 500/125 mg 8-hourly for 5 days
- Penicillin allergy, not pregnant: doxycycline 200 mg on day 1, then 100 mg daily for 4 days
- Avoid fluoroquinolones unless there is no other option
- Worse after 2 to 3 days on treatment: reassess
- Path rejoins step 04Shared downstream outcome
If No16Action Criteria not met: viral rhinosinusitis, no antibiotic
Give symptom relief and safety-net advice. Review if symptoms last over 10 days or get worse again after first getting better.
- Path rejoins step 04Shared downstream outcome
- Cough
17Action Acute cough: check for pneumonia, then usually no antibiotic
Suspect pneumonia if heart rate 100/min or more, breathing rate 24/min or more, temperature 38 °C or more, or focal chest signs: get a chest X-ray and use the community-acquired pneumonia pathway.
- No pneumonia signs: acute bronchitis, almost always viral; no antibiotic; cough can last 3 to 4 weeks
- Higher risk of complications (over 65 with 2 or more of: admission in past year, diabetes, heart failure, oral steroids; over 80 with 1 or more; significant heart, kidney, liver or neuromuscular disease): consider an immediate or back-up antibiotic
- If an antibiotic is needed: amoxicillin 500 mg 8-hourly for 5 days, or (not in pregnancy) doxycycline 200 mg on day 1, then 100 mg daily for 4 days
- Asthma or COPD flare: use that pathway
- Cough 2 weeks or more with paroxysms, whoop or vomiting after cough: test for pertussis (PCR)
- Pertussis likely and cough began within 3 weeks: azithromycin 500 mg on day 1, then 250 mg daily on days 2 to 5; notify public health; keep away from infants and late pregnancy until 5 days of treatment
- Path rejoins step 04Shared downstream outcome
Guideline Source
ACP/CDC High-Value Care Advice: Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults (Harris et al., Ann Intern Med 2016), with CDC adult outpatient treatment recommendations and IDSA 2012 group A streptococcal pharyngitis guideline
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults 18 years and over who are not immunocompromised and have no chronic lung disease flare; children, immunocompromised patients and asthma or COPD flares need other guidance
- Does not cover antiviral treatment for influenza or COVID-19, or acute otitis media
- Antibiotic choice can differ with local resistance and local guidelines (Australia: eTG Antibiotic)
- Watchful waiting and back-up prescriptions need clear safety-net advice and a way to return
Contraindicated Populations
Children under 18 yearsImmunocompromised patientsAsthma, COPD, bronchiectasis or cystic fibrosis flare
Applicable Regions
USAUUKEU
AU: 2025 Australian ARF/RHD guideline: in people at high risk of rheumatic fever, swab every sore throat and give antibiotic at once (benzathine benzylpenicillin G IM preferred). Others: swab only with signs of tonsillitis and treat only if strep A positive. eTG first line for acute bacterial rhinosinusitis: amoxicillin 500 mg 8-hourly for 5 days.
UK: NICE NG84, NG79 and NG120: FeverPAIN or Centor for sore throat; no antibiotic or a back-up prescription for most. Sinusitis first choice: phenoxymethylpenicillin 500 mg 4 times a day for 5 days.
US: CDC adult outpatient treatment recommendations and ACP/CDC 2016 advice; IDSA 2012 group A streptococcal pharyngitis guideline.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Upper Respiratory Infection Management (IDSA/CDC)?
The Upper Respiratory Infection Management (IDSA/CDC) is a management clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on ACP/CDC High-Value Care Advice: Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults (Harris et al., Ann Intern Med 2016), with CDC adult outpatient treatment recommendations and IDSA 2012 group A streptococcal pharyngitis guideline.
What guideline is the Upper Respiratory Infection Management (IDSA/CDC) based on?
This algorithm is based on ACP/CDC High-Value Care Advice: Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults (Harris et al., Ann Intern Med 2016), with CDC adult outpatient treatment recommendations and IDSA 2012 group A streptococcal pharyngitis guideline (DOI: 10.7326/M15-1840).
What are the limitations of the Upper Respiratory Infection Management (IDSA/CDC)?
Known limitations include: Adults 18 years and over who are not immunocompromised and have no chronic lung disease flare; children, immunocompromised patients and asthma or COPD flares need other guidance; Does not cover antiviral treatment for influenza or COVID-19, or acute otitis media; Antibiotic choice can differ with local resistance and local guidelines (Australia: eTG Antibiotic); Watchful waiting and back-up prescriptions need clear safety-net advice and a way to return. Individual patient factors may require deviation from these recommendations.
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