Upper respiratory tract infection (URI) is one of the most common illnesses seen in primary care and is ranked as one of the top reasons for visits to clinicians.1 These infections create a heavy burden on financial and time-related resources for both the patient and healthcare system. Patients often expect some form of treatment or an antibiotic prescription when seen for a URI.  However, antibiotic resistance rates continue to rise as antibiotic overprescribing increases. Primary care clinicians, therefore, should be knowledgeable about research on alternative treatments, such essential oils, Echinacea, elderberry, and zinc, to manage URI symptoms in cases where antibiotic therapy is not indicated.

Antibiotic Resistance

The Centers for Disease Control and Prevention (CDC) reports antibiotic resistance as a global public health concern with more than 2.8 million people with antibiotic-resistant infections each year, resulting in 35,000 deaths annually.2,3 The agency recommends healthcare providers improve their antibiotic prescribing practices by following the core elements of outpatient antibiotic stewardship: commitment to patients to discuss appropriate antibiotic use, action for policy and practice, tracking and reporting, and education and expertise.4 These core elements provide a framework that can guide outpatient prescribing practices and lead to the most appropriate antibiotic use. It is also important for clinicians to provide education to patients and their caregivers about appropriate antibiotic use and the reasons for its importance.

Common Causes of Upper Respiratory Tract Infections

URIs are generally defined as self-limited infections that occur due to irritation and swelling of the upper airways secondary to an infectious pathology.5 URIs can encompass a wide variety of etiologies, both bacterial and viral, such as influenza, acute rhinosinusitis, pharyngitis, and the common cold. Of the bacterial presentations, the most common is Streptococcus pyogenes, a Group A streptococcus.5

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The majority of URIs, however, are viral in nature and are most commonly caused by rhinovirus as well as adenovirus, parainfluenza virus, respiratory syncytial virus, enterovirus, and coronavirus.5 Upper respiratory tract infections associated with the common cold tend to occur in a seasonal pattern occurring 2 to 3 times throughout the year. Cases of the common cold from rhinovirus infection tend to peak in fall months.5 Diagnosis is usually made clinically based upon the patient’s history, and without other pathology noted on physical examination.5 Risk factors for the common cold are listed in Table 1.5

Table 1. Risk Factors and Common Symptoms of URIs 5

Risk FactorsCommon Symptoms
● Smoking
● History of asthma or allergic rhinitis
● Compromised immune system
● Frequent contact with children
● Facial anatomical abnormalities
(eg, nasal polyps)
● Cough
● Sore throat
● Runny nose
● Nasal congestion
● Headache
● Low-grade fever
● Sneezing
● Sinus pressure
● Fatigue  

Traditional Pharmacotherapy

Many over-the-counter (OTC) preparations are available to treat URI symptoms such as antitussives, antihistamines, and decongestants. However, many patients do not know how to use these preparations appropriately or effectively. In recent years there has been an increasing trend in patients seeking natural OTC medications as part of a self-care regimen.6 Patients don’t always consult with their healthcare provider before taking these agents. Thus, the healthcare team should educate patients when they do come in for URI treatment on which OTC medications are safe and effective. This is especially important for patients with other comorbidities or who are taking other medications.

Common OTC remedies for symptom control include guaifenesin (expectorant), pseudoephedrine (decongestant), and antihistamines (decongestant).7 These medications help provide symptom relief but can also have significant side effects and potential drug interactions. Patients who are on multiple medications and have comorbidities should consult with either the pharmacist or their healthcare provider before taking these medications and be educated on when to seek additional medical care if their symptoms are not improving.  

Vitamin C

Vitamin C (ascorbic acid) is a commonly used OTC remedy for URIs. The properties of this vitamin supplement are described to boost the immune system and provide an antioxidant effect.7 Vitamin C can be consumed through dietary sources, such as citrus fruits and fresh vegetables, or through supplements purchased OTC.

A meta-analysis by Bucher and White showed that vitamin C supplementation did not have an overall effect on incidences of colds, but did have an effect on duration when consumed at higher doses (>0.2 g/day).9 A meta-analysis by Vorilhon et al evaluated the efficacy of vitamin C supplementation in children for both prevention and reduction in duration of upper respiratory symptoms.9 The study authors concluded that no preventative effects were found but vitamin C did decrease the duration of URI.

Vitamin C may be safest when consumed through dietary sources such as citrus fruits, tomatoes, strawberries, and broccoli. Side effects of high doses of vitamin C supplements for sustained periods are not well documented but consideration for cardiovascular disease and kidney stones should be considered.10