When should antibiotics be used in the treatment of Upper Respiratory Tract Infections (URTI) according to Australian guidelines?

When to Use Antibiotics in Upper Respiratory Tract Infections (URTI) According to Australian Guidelines

Antibiotics should NOT be used for most upper respiratory tract infections as they are predominantly viral in origin, and should only be considered when specific criteria for bacterial infection are met.

General Principles for Antibiotic Use in URTI

• Most URTIs are viral in origin and require only symptomatic treatment 1
• Inappropriate antibiotic use contributes to antibiotic resistance, adverse events, and unnecessary healthcare costs 2

Specific Indications for Antibiotics in URTI

When to Consider Antibiotics:

• Symptoms persisting beyond 7-10 days 1
• High fever (>38.5°C) persisting for more than 3 days 1
• Worsening symptoms after initial improvement (biphasic illness) 1
• Clear signs of bacterial infection 1

High-Risk Patients Who May Need Earlier Antibiotic Consideration:

• Patients aged >75 years with fever 3
• Patients with cardiac failure 3
• Patients with insulin-dependent diabetes mellitus 3
• Patients with serious neurological disorders (stroke, etc.) 3

Specific Conditions and Antibiotic Recommendations

Suspected Bacterial Rhinosinusitis

• Consider antibiotics only if symptoms persist beyond 7-10 days or worsen after initial improvement 1

Acute Exacerbations of COPD

• Antibiotics indicated when all three symptoms are present: increased dyspnoea, increased sputum volume, and increased sputum purulence 3
• Also consider antibiotics for exacerbations in patients with severe COPD 3

Suspected Pneumonia

• Antibiotics indicated when acute cough is accompanied by one of: new focal chest signs, dyspnoea, tachypnoea, or fever lasting >4 days 3
• Chest radiograph should be performed to confirm diagnosis 3

Antibiotic Selection When Indicated

1. First-line options:

   • Amoxicillin or tetracycline 3, 1

2. Alternatives for hypersensitivity:

   • Macrolides such as azithromycin, clarithromycin, erythromycin, or roxithromycin (in areas with low pneumococcal macrolide resistance) 3, 1

3. When significant resistance to first-line agents exists:

   • Consider levofloxacin or moxifloxacin 3

Patient Monitoring and Follow-up

• Advise patients to return if symptoms persist beyond 3 weeks 3
• Clinical effects of antibiotic treatment should be expected within 3 days 3
• Patients should contact their doctor if improvement is not observed within this timeframe 3
• Patients should return if fever exceeds 4 days, dyspnea worsens, or general condition deteriorates 3

Common Pitfalls to Avoid

1. Prescribing antibiotics for viral URTIs:

   • Studies show that many URTIs are unnecessarily treated with antibiotics 4, 2
   • Educational interventions in Australia have reduced inappropriate antibiotic prescribing by 14% 5

2. Prescribing due to perceived patient expectations:

   • More than half of Australian GPs self-report prescribing antibiotics for URTIs to meet patient expectations 4
   • Better doctor-patient communication can help address this issue

3. Inappropriate use of symptomatic treatments:

   • Expectorants, mucolytics, antihistamines, and bronchodilators should not be prescribed in acute LRTI in primary care 3
   • For dry, bothersome cough, dextromethorphan and codeine can be considered 3

By following these evidence-based guidelines, clinicians can ensure appropriate antibiotic use for URTIs, helping to combat antibiotic resistance while providing optimal patient care.