What are safe antibiotics during lactation for an upper respiratory infection (URI)?

From the Guidelines

Several antibiotics are safe to use during lactation for treating upper respiratory infections, with first-line options including amoxicillin and amoxicillin-clavulanate, which have minimal transfer into breast milk and pose very low risk to nursing infants. The choice of antibiotic should be based on the likely bacterial pathogens and the patient's medical history, including any allergies or previous antibiotic use.

• Amoxicillin (500 mg three times daily for 5-7 days) and amoxicillin-clavulanate (875/125 mg twice daily for 5-7 days) are considered safe options 1.
• Cephalosporins, such as cefuroxime (500 mg twice daily for 7-10 days), are also considered safe for use during lactation 1.
• For patients with penicillin allergies, azithromycin (500 mg on day 1, then 250 mg daily for days 2-5) and clarithromycin (500 mg twice daily for 7-10 days) are good alternatives 1.
• It's essential to note that most upper respiratory infections are viral and don't require antibiotics at all, and antibiotics should only be prescribed when there's clear evidence of bacterial infection, such as purulent discharge, severe symptoms lasting more than 10-14 days, or worsening symptoms after initial improvement 1.
• When breastfeeding, mothers should take antibiotics immediately after nursing to minimize infant exposure and stay well-hydrated to maintain milk supply.
• The most recent and highest quality study, published in 2020, provides guidance on the safe use of antibiotics during lactation, including the use of amoxicillin, amoxicillin-clavulanate, and cephalosporins 1.

From the FDA Drug Label

1. 3 Nursing Mothers Penicillins have been shown to be excreted in human milk. Amoxicillin use by nursing mothers may lead to sensitization of infants. Caution should be exercised when amoxicillin is administered to a nursing woman.

Amoxicillin use during lactation for upper respiratory infection requires caution, as it may lead to sensitization of infants. However, the label does not explicitly state that amoxicillin is contraindicated during lactation.

• The decision to use amoxicillin during lactation should be made with caution and under the guidance of a healthcare professional, weighing the benefits and potential risks to the infant 2.

From the Research

Safe Antibiotics for Upper Respiratory Infections during Lactation

• The following antibiotics are considered safe for use during lactation:
  • Penicillins 3, 4
  • Macrolides 3, 4
  • Aminopenicillins 4
  • Clavulanic acid 4
  • Cephalosporins 4
  • Metronidazole at low dosages 4
• Fluoroquinolones should not be administered as first-line treatment, but if they are indicated, breast feeding should not be interrupted because the risk of adverse effects is low 4
• Antibiotics that should be avoided during lactation include:
  • Tetracyclines 3
  • Cotrimoxazole 3
  • Chloramphenicol 3
  • Quinolones 3

Upper Respiratory Infections and Antibiotic Use

• Antibiotics are often overused in the treatment of upper respiratory tract infections 5, 6
• Antibiotics should only be used in cases where they are warranted, such as:
  • Acute otitis media 5, 6
  • Group A beta-hemolytic streptococcal pharyngitis 5, 6
  • Epiglottitis 5, 6
  • Bronchitis caused by pertussis 5
  • Persistent cases of rhinosinusitis 5, 6
• Antibiotics should not be used to treat:
  • The common cold 5, 6
  • Influenza 6
  • COVID-19 6
  • Laryngitis 5, 6