Antibiotics in Upper Respiratory Tract Infections
Direct Answer
Antibiotics should NOT be prescribed for most URTIs, as they are predominantly viral and self-limiting. 1, 2 Reserve antibiotics only for specific bacterial complications: acute bacterial rhinosinusitis meeting strict clinical criteria, group A streptococcal pharyngitis with confirmation, and acute otitis media with validated diagnostic criteria. 1
When Antibiotics Are NOT Indicated
Most URTIs are viral and resolve without antibiotics—more than 90% of acute cough illnesses in healthy patients are caused by viruses. 2
- Common cold (acute rhinopharyngitis): Never use antibiotics 3, 4
- Acute bronchitis in healthy adults: Do not prescribe antibiotics, even with purulent sputum 2, 5
- Influenza and COVID-19: Antibiotics provide no benefit 3
- Laryngitis: Antibiotics are not indicated 3
- Nonspecific URI with fever and cough <3 days: Symptomatic treatment only 2
Critical pitfall: Purulent nasal discharge or colored sputum (green/yellow) does NOT indicate bacterial infection and should NOT trigger antibiotic prescription. 2, 4 This is viral inflammation, not bacterial superinfection.
When Antibiotics ARE Indicated
Acute Bacterial Rhinosinusitis (ABRS)
Only prescribe antibiotics when ONE of these three clinical patterns is present: 1
- Persistent symptoms without improvement for >10 days
- Severe symptoms for ≥3 consecutive days: fever >39°C (102.2°F) AND purulent nasal discharge AND facial pain
- Double worsening: Initial improvement followed by worsening symptoms with new fever, headache, or increased nasal discharge
Fewer than 2% of viral URIs progress to bacterial sinusitis. 1 The American College of Physicians and CDC recommend watchful waiting as initial management for uncomplicated cases, with supportive care (intranasal saline, intranasal corticosteroids) to potentially decrease antibiotic need. 1
First-line antibiotic: Amoxicillin-clavulanate is preferred by IDSA 1, though some societies recommend amoxicillin alone 1. Alternative: doxycycline or respiratory fluoroquinolone (levofloxacin, moxifloxacin) 1
Group A Streptococcal Pharyngitis
Confirm diagnosis with rapid antigen testing before prescribing antibiotics. 1, 5 Empiric therapy may be acceptable only if validated clinical scoring suggests high likelihood of streptococcal infection. 5
Acute Otitis Media
Diagnose only with all three criteria: 1, 5
- Abrupt onset
- Signs of middle ear effusion
- Symptoms of middle ear inflammation
Observation without immediate antibiotics is appropriate for certain children. 1, 5
Clinical Assessment Algorithm
For patients presenting with fever and cough: 2
Duration <2-3 days: Symptomatic treatment, no antibiotics 2
Duration >3 days with persistent fever >38°C: Consider bacterial complication 1, 2
Assess for pneumonia if ANY of these present: 2
- Tachycardia (>100 bpm)
- Tachypnea (>24 breaths/min)
- Fever >38°C for >3 days
- Abnormal chest examination
If pneumonia suspected: Obtain chest radiograph for confirmation 2
Essential practice: Clinical follow-up with reassessment at 2-3 days is mandatory, as early differentiation between viral and bacterial causes is often impossible. 1, 2
Antibiotic Selection When Indicated
For upper respiratory tract bacterial infections (confirmed streptococcal pharyngitis, ABRS, AOM): 6
- First-line: Amoxicillin for β-lactamase-negative organisms 6
- For β-lactamase producers or treatment failure: Amoxicillin-clavulanate 1
- Penicillin allergy: Macrolides, doxycycline, or respiratory fluoroquinolones 1
Target organisms: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis 1, 6
Special Populations Requiring Lower Threshold
Immediate antibiotics may be appropriate for: 2
- Age >75 years with fever AND (cardiac failure OR insulin-dependent diabetes OR serious neurological disorders)
- Chronic obstructive pulmonary disease with respiratory insufficiency (dyspnea at rest, FEV1 <35%, hypoxemia) 1
- Suspected or confirmed pneumonia 2
Consequences of Inappropriate Prescribing
The number needed to harm (8) exceeds the number needed to treat (18) for acute rhinosinusitis. 1 Inappropriate antibiotic use causes:
- Avoidable adverse drug events including anaphylaxis 1
- Antimicrobial resistance development 1
- Increased healthcare costs 1
- Masking of true infectious disease diagnosis 1
Current practice shows 24.8% of viral URTI patients receive unnecessary antibiotics, predominantly penicillins and cephalosporins. 7 More than 80% of sinusitis visits result in antibiotic prescriptions, though most are unnecessary. 1
Supportive Care Recommendations
For symptomatic relief without antibiotics: 2
- Analgesics for pain
- Antipyretics for fever
- Intranasal saline irrigation 1
- Intranasal corticosteroids 1
- Decongestants (systemic or topical)
- First-generation antihistamines
- Cough suppressants
These provide comfort but do not shorten illness duration. 2