When is the right time to prescribe antibiotics in Upper Respiratory Tract Infections (URTI)?

From the Guidelines

Antibiotics should only be prescribed for Upper Respiratory Tract Infections (URTIs) when there is strong evidence of bacterial infection, such as persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days. The decision to prescribe antibiotics in URTIs should be guided by clinical indicators that suggest a bacterial etiology, as most URTIs are viral in nature and will not respond to antibiotics 1.

Clinical Indicators for Antibiotic Use

• Persistent symptoms for more than 10 days
• Onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days
• Symptoms suggestive of group A streptococcal pharyngitis, such as persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms, confirmed by rapid antigen detection test and/or culture for group A Streptococcus 1
• Worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening) 1

Antibiotic Treatment

For bacterial sinusitis, amoxicillin 500mg three times daily for 5-7 days is typically first-line, with amoxicillin-clavulanate 875/125mg twice daily as an alternative for more severe cases. For streptococcal pharyngitis, penicillin V 500mg twice daily for 10 days or amoxicillin 500mg twice daily for 10 days is recommended.

Delayed Antibiotic Prescribing

Delayed antibiotic prescribing (providing a prescription with instructions to fill only if symptoms worsen or persist) is a useful strategy for uncertain cases, as it can help reduce unnecessary antibiotic use while still providing patients with access to antibiotics if their condition worsens 1.

Importance of Judicious Prescribing

Unnecessary antibiotic use contributes to antibiotic resistance, disrupts normal gut flora, and exposes patients to potential adverse effects without clinical benefit, which is why judicious prescribing based on likely bacterial etiology is essential 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of amoxicillin and other antibacterial drugs, amoxicillin should be used only to treat infections that are proven or strongly suspected to be caused by bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

The right time to prescribe antibiotics in Upper Respiratory Tract Infections (URTI) is when the infection is proven or strongly suspected to be caused by bacteria. The decision to prescribe antibiotics should be based on:

• Culture and susceptibility information, if available
• Local epidemiology and susceptibility patterns, if culture and susceptibility information are not available It is essential to use antibiotics judiciously and only when necessary to reduce the development of drug-resistant bacteria 2.

From the Research

Determining the Right Time for Antibiotic Prescription in URTI

The decision to prescribe antibiotics in Upper Respiratory Tract Infections (URTI) should be based on specific criteria to ensure appropriate use and minimize antimicrobial resistance.

• Patient Assessment: It is crucial to assess the patient's condition and identify those who may require antibiotics, further investigations, and/or hospital referral 3.
• High-Risk Patients: Immediate antibiotics or further investigation and/or management are recommended for patients who are systemically very unwell, have features suggestive of serious illness and complications, or have pre-existing comorbidities 3.
• Centor Criteria: Antibiotics should also be considered for patients with three or more Centor criteria 3.
• Delayed Prescribing Strategy: For other cases, such as acute otitis media, acute sore throat/pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis, or acute cough/acute bronchitis, a no prescribing or delayed prescribing strategy is advocated 3.
• Antimicrobial Susceptibility: Knowing the antimicrobial susceptibility patterns in the population is essential for successful treatment of bacterial URTI 4.
• Inhaled Antibiotic Therapy: Inhaled antibiotic therapy may be considered for the treatment of URTIs, particularly for chronic rhinosinusitis in adults, but further studies are needed to determine its effectiveness 5.

Considerations for Antibiotic Prescription

When prescribing antibiotics for URTI, consider the following:

• Choice of Antibiotic: The choice of antibiotic should be based on the suspected or confirmed causative pathogen and its antimicrobial susceptibility pattern 4.
• Resistance Patterns: The increasing resistance of Streptococcus pneumoniae to fluoroquinolones and macrolides should be taken into account when selecting an antibiotic 4.
• Appropriate Use: Antibiotics should only be prescribed when necessary, and their use should be guided by evidence-based guidelines to minimize the development of antimicrobial resistance 6, 7.