Why are antibiotics prescribed for Upper Respiratory Infections (URIs)?

Antibiotics for Upper Respiratory Infections (URIs)

Most upper respiratory tract infections are caused by viruses and do not require antibiotics. Antibiotics should only be prescribed for URIs when there is strong evidence of bacterial infection, as inappropriate antibiotic use contributes to antibiotic resistance, causes avoidable adverse events, and adds unnecessary medical costs 1, 2.

When Antibiotics Are Indicated for URIs

Antibiotics should be considered only in specific bacterial URI conditions:

1. Acute Bacterial Sinusitis - antibiotics indicated when:

   • Symptoms persist >10 days without improvement
   • Severe symptoms with purulent discharge and high fever
   • Worsening symptoms after initial improvement ("double worsening") 2

2. Streptococcal Pharyngitis (Group A Strep)

   • Only after confirmation with appropriate testing 1, 3

3. Acute Otitis Media

   • Following stringent diagnostic criteria 1

4. Bacterial Respiratory Infections

   • For beta-lactamase-producing isolates of Haemophilus influenzae and Moraxella catarrhalis 4

Recommended Antibiotics When Indicated

• First-line for bacterial sinusitis: Amoxicillin-clavulanate 2, 4
• Alternatives: Cefpodoxime-proxetil or cefuroxime-axetil 2
• For penicillin allergy: Doxycycline or macrolides (for specific cases) 2, 5

Inappropriate Antibiotic Use

Antibiotics should NOT be prescribed for:

• Common cold
• Viral rhinosinusitis
• Acute bronchitis (in most cases)
• Laryngitis
• COVID-19
• Influenza 3, 6

Common Pitfalls in URI Management

1. Misinterpreting purulent secretions as bacterial infection

   • Purulent nasal or throat secretions do not predict bacterial infection or benefit from antibiotics 6

2. Prescribing under patient pressure

   • Up to 42.2% of URI encounters result in unnecessary antibiotic prescriptions 7

3. Overuse in high-volume settings

   • Providers in urgent care settings and rural practices tend to prescribe antibiotics more frequently 7

4. Broad-spectrum overuse

   • Using broad-spectrum antibiotics when narrower-spectrum alternatives would be appropriate 1

Best Practices for URI Management

1. Apply stringent diagnostic criteria before diagnosing bacterial infections 1

2. Provide symptomatic treatment for viral URIs:

   • Acetaminophen or NSAIDs for pain/fever
   • Adequate hydration
   • Rest
   • Saline nasal irrigation
   • Honey for cough (in patients >1 year old) 2

3. Patient education:

   • Explain that most URIs are viral and self-limiting (typically 7-10 days)
   • Discuss risks of antibiotic resistance
   • Provide clear return precautions 2

4. Follow-up if symptoms worsen or fail to improve after 72 hours 2

By following these evidence-based guidelines, clinicians can ensure that antibiotics are prescribed only when they will provide clinical benefit, thereby reducing antibiotic resistance while maintaining quality patient care.