Indications for Antibiotics in Upper Respiratory Tract Infections (URTI)

Antibiotics are NOT indicated for most uncomplicated upper respiratory tract infections, which are primarily viral in origin. 1, 2

General Principles for Antibiotic Use in URTIs

The primary principle in managing URTIs is determining the likelihood of a bacterial infection using stringent and validated clinical criteria 1, 3
Antibiotic prescribing should be limited to clinical situations where efficacy has been proven to reduce bacterial resistance and adverse events 1
Routine use of antibiotics for viral URTIs is not recommended due to lack of benefit and potential for significant adverse effects 2

Antibiotic treatment is NOT justified in uncomplicated acute common cold in adults or children 1
Antibiotics have not been shown to affect symptom duration or prevent complications 1
Antibiotics are only recommended in cases of bacterial complications 1
Treatment should focus on symptomatic relief (antipyretics, nasal hygiene) 1, 3

Antibiotics are indicated ONLY for Group A Streptococcal (GAS) pharyngitis, confirmed by rapid antigen testing or culture 1, 3
Testing for GAS is recommended only when at least 2 of the following are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, or absence of cough 3
Empiric treatment without testing is not recommended 3
First-line treatment is penicillin or amoxicillin 3, 4

Antibiotic therapy is indicated when the diagnosis of acute purulent maxillary sinusitis is established 1
Specific indications include:
- URI symptoms that are worsening (new fever, worsening cough or nasal discharge after initial improvement) 1
- Severe symptoms (fever ≥39°C, purulent nasal discharge) 1
- Persistent symptoms without improvement (nasal discharge or daytime cough >10 days) 1
Antibiotics are definitely indicated for frontal, ethmoidal, or sphenoidal sinusitis due to higher risk of complications 1
First-line treatment includes amoxicillin with or without clavulanate 1, 3

For children under 2 years of age, antibiotic therapy is recommended 1
For children over 2 years, antibiotics are indicated only with marked symptoms (high fever, intense earache) 1
Diagnosis requires middle ear effusion AND signs of inflammation (moderate/severe bulging of tympanic membrane, otorrhea not due to otitis externa, or mild bulging with ear pain/erythema) 1, 3
First-line treatment is amoxicillin (90 mg/kg/day) 3, 5

Antibiotics are NOT indicated except in cases of AOM that continue beyond 3 months 1

Amoxicillin remains the drug of choice for most bacterial URTIs due to effectiveness against common pathogens and favorable safety profile 3, 5
For upper respiratory infections, amoxicillin is indicated for susceptible (β-lactamase-negative) isolates of Streptococcus species, Streptococcus pneumoniae, Staphylococcus species, or Haemophilus influenzae 5
Second-line options may include amoxicillin-clavulanate, certain cephalosporins, macrolides (in case of penicillin allergy), or respiratory fluoroquinolones (in specific situations) 1, 4

Prescribing antibiotics based solely on patient expectations - studies show 82% of patients expect antibiotics for URTIs despite lack of indication 6
Using broad-spectrum antibiotics as first-line treatment when narrow-spectrum options are appropriate 1
Prescribing antibiotics for isolated redness of the tympanic membrane without other signs of infection 1
Failing to distinguish between viral and bacterial etiologies based on specific clinical criteria 1, 3
Prescribing antibiotics for purulent rhinitis without other symptoms of bacterial infection - evidence shows no benefit 2

Antibiotic prescribing for uncomplicated URTIs has decreased in recent years (from 18.0% to 8.8% in one large study), but inappropriate prescribing still occurs 7
Specialists (particularly pediatricians) tend to prescribe antibiotics less frequently than general practitioners for URTIs 7, 8