What antibiotics are recommended as first-line treatment for a child with an upper respiratory tract infection?

First-Line Antibiotics for Upper Respiratory Tract Infections in Children

For most viral upper respiratory tract infections in children, antibiotics are not recommended as first-line treatment since they provide no benefit and may cause harm.

Determining When Antibiotics Are Needed

• Most upper respiratory tract infections (URTIs) in children are viral in origin and do not require antibiotic therapy 1, 2
• Clinical assessment should focus on distinguishing viral from bacterial infections, as unnecessary antibiotic use contributes to antimicrobial resistance 2

When Antibiotics Should Be Avoided:

• Common cold (viral rhinitis) - antibiotics provide no benefit 2, 3
• Viral laryngitis - antibiotics not indicated 2
• Uncomplicated viral bronchitis - first-line antibiotics not recommended 4
• When symptoms are already improving, suggesting resolution of viral infection 5

When Antibiotics Are Indicated:

For Acute Bacterial Rhinosinusitis (ABRS):

• Amoxicillin-clavulanate is recommended over amoxicillin alone as first-line therapy for ABRS in children (strong recommendation) 4
• Duration should be 10-14 days for children with ABRS 4
• For children with penicillin allergy (non-Type I): cefpodoxime proxetil, cefuroxime axetil, or cefdinir 4
• For children with Type I penicillin allergy: TMP/SMX, azithromycin, clarithromycin, or erythromycin (note: these have limited effectiveness with potential 20-25% bacterial failure rate) 4

For Community-Acquired Pneumonia:

• For children under 5 years:

  • Amoxicillin is first choice for oral therapy (effective against majority of pathogens) 4
  • Dose: 45-90 mg/kg/day 4

• For children 5 years and older:

  • Macrolide antibiotics (azithromycin, clarithromycin) may be used as first-line due to higher prevalence of mycoplasma pneumonia 4
  • If Streptococcus pneumoniae is suspected: amoxicillin remains first choice 4

For Acute Otitis Media:

• Antibiotic therapy recommended for children under 2 years of age 4
• For children over 2 years, antibiotics may be withheld unless symptoms are severe (high fever, intense ear pain) 4
• First-line options:
  • Amoxicillin-clavulanate or high-dose amoxicillin 4
  • For otitis associated with purulent conjunctivitis (likely H. influenzae): cefixime, cefpodoxime-proxetil, amoxicillin-clavulanate, or cefuroxime-axetil 4
  • For febrile painful otitis (likely pneumococcal): amoxicillin, cefuroxime-axetil, or cefpodoxime-proxetil 4

For Streptococcal Pharyngitis/Tonsillitis:

• Penicillin remains the drug of choice for confirmed Group A beta-hemolytic streptococcal (GABHS) pharyngitis 1
• Alternative options: oral cephalosporins (cefaclor, cephalexin), amoxicillin, or macrolides 1

Important Considerations

• Antibiotic exposure selects for antibiotic resistance; therefore, limiting exposure whenever possible is preferred 4
• Recent antibiotic use (within 4-6 weeks) should influence antibiotic selection due to increased risk of resistant organisms 4
• Adjunctive treatments to consider:
  • Intranasal saline irrigation for ABRS 4
  • Intranasal corticosteroids for ABRS, especially in children with history of allergic rhinitis 4

Monitoring Response to Treatment

• Failure to respond to antibiotics within 72 hours should prompt reevaluation and consideration of alternative therapy 4
• For pneumonia, fever should resolve within 48-72 hours of appropriate antibiotic therapy 4
• Treatment duration should be the shortest effective course to minimize antimicrobial resistance 4

Common Pitfalls to Avoid

• Prescribing antibiotics for viral URTIs - studies show unnecessary antibiotic prescribing rates of 8.8-58% for URTIs in children 6, 7
• Using macrolides as first-line for suspected pneumococcal infections - amoxicillin remains more effective 4
• Failing to adjust therapy based on recent antibiotic exposure 4
• Not considering local resistance patterns when selecting empiric therapy 4