Recommended Antibiotics for Bacterial Upper Respiratory Tract Infections in Children
Amoxicillin is the first-line antibiotic treatment for children with bacterial upper respiratory tract infections (URTIs), with dosing of 45-90 mg/kg/day depending on infection severity and local resistance patterns. 1, 2
First-Line Treatment Options
- Amoxicillin has traditionally been the recommended first-line agent for bacterial URTIs because Streptococcus pneumoniae is the most important causative pathogen 1
- For mild to moderate infections, amoxicillin should be dosed at 45 mg/kg/day divided into two doses or 40 mg/kg/day divided into three doses 2
- For severe infections or when drug-resistant pathogens are suspected, higher dosing of 90 mg/kg/day is recommended 2
- For children under 3 years with suspected bacterial pneumonia, amoxicillin 80-100 mg/kg/day in three daily doses is recommended 1
When to Consider Alternative Antibiotics
Amoxicillin-clavulanate should be considered in certain instances:
In areas with high prevalence of penicillin-resistant S. pneumoniae, high-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) is recommended 2
Treatment Duration
- For acute otitis media, treatment duration should be 5 days for uncomplicated cases 2
- For acute bacterial rhinosinusitis, treatment duration should be 5-8 days 2
- Treatment should generally continue for 48 to 72 hours beyond the time that the patient becomes asymptomatic 3
Specific URTI Conditions
Acute Otitis Media
- Amoxicillin is the first choice at 40 mg/kg/day in divided doses twice daily for 5 days 2, 4
- For treatment failure with amoxicillin, switch to amoxicillin-clavulanate or ceftriaxone 4
Acute Bacterial Sinusitis
- Amoxicillin is the drug of choice 5
- When symptoms persist or worsen, amoxicillin-clavulanate or cefpodoxime proxetil are recommended 4
Streptococcal Pharyngitis
- Diagnosis should be confirmed with rapid antigen detection test or throat culture 5
- Amoxicillin 50-75 mg/kg/day in 2 doses for 10 days is recommended 2
Important Clinical Considerations
- Evaluate response to therapy after 48-72 hours; lack of improvement may indicate treatment failure requiring change in antibiotic or reevaluation 2
- Macrolides and oral third-generation cephalosporins have high rates of pneumococcal resistance, making them poor choices for most children with suspected bacterial URTIs 1
- Observation (wait-and-see approach) may be considered as an alternative strategy to immediate antibiotic therapy for older children without severe symptoms 1
- The benefits of antibiotic therapy appear to be greatest for patients with S. pneumoniae infection compared with other bacterial causes of URI, which may have higher rates of spontaneous resolution 1
Adverse Effects and Precautions
- Antibiotics can cause adverse events ranging from mild (diarrhea and rash) to severe (Stevens-Johnson syndrome) and life-threatening reactions (anaphylaxis) 1
- Amoxicillin-clavulanate has a higher rate of adverse events (particularly diarrhea) compared to amoxicillin alone 1
- There is growing evidence that early-life antibiotic exposures may disrupt the microbiome, potentially contributing to long-term health effects such as inflammatory bowel disease, obesity, eczema, and asthma 1
- Judicious use of antibiotics is essential to minimize the impact of antibiotic overuse on resistance in individuals and communities 1
Antibiotic Selection Algorithm
- Confirm bacterial etiology of URTI when possible
- For first episode with mild-moderate symptoms: Amoxicillin 45 mg/kg/day divided twice daily 2
- For severe symptoms OR recent antibiotic use OR high local resistance: High-dose amoxicillin (90 mg/kg/day) or amoxicillin-clavulanate 1, 2
- For treatment failure after 48-72 hours: Switch to amoxicillin-clavulanate or consider parenteral therapy 4
- For penicillin allergy: Consider macrolides, though these have lower efficacy against common URTI pathogens 2