What antibiotics are used to treat congestion and cough caused by a bacterial infection?

Antibiotics Are Generally NOT Recommended for Congestion and Cough

In the vast majority of cases, antibiotics should not be prescribed for congestion and cough because more than 90% of these respiratory symptoms are caused by viral infections, not bacterial infections. 1

When Antibiotics Are NOT Indicated

Clinicians should not initiate antibiotic therapy in patients with acute bronchitis (cough and congestion) unless pneumonia is suspected. 1 This is the most critical high-value care recommendation from the American College of Physicians and CDC.

Key Evidence Against Routine Antibiotic Use:

• Acute bronchitis with cough is viral in over 90% of cases and does not benefit from antibiotics 1
• Purulent (green or yellow) sputum does NOT indicate bacterial infection—it simply reflects inflammatory cells, not bacteria 1
• Systematic reviews of 15 randomized controlled trials found limited evidence supporting antibiotics for acute bronchitis, with a trend toward increased adverse events 1
• A randomized trial comparing amoxicillin-clavulanate to placebo showed no significant difference in days to cough resolution 1
• Macrolides (azithromycin) caused significantly more adverse events than placebo in acute bronchitis patients 1

For Postinfectious Cough:

Antibiotics have no role in postinfectious cough (lasting 3-8 weeks after respiratory infection) because the cause is not bacterial infection. 1 Instead, consider:

• Inhaled ipratropium as first-line therapy 1
• Inhaled corticosteroids if cough persists and affects quality of life 1
• Short course of prednisone (30-40 mg daily) for severe paroxysms after ruling out other causes 1

When to Consider Antibiotics: Ruling Out Pneumonia

Before prescribing antibiotics, you must distinguish bronchitis from pneumonia. For healthy immunocompetent adults under 70 years, pneumonia is unlikely in the absence of ALL of the following: 1

• Tachycardia (heart rate >100 beats/min)
• Tachypnea (respiratory rate >24 breaths/min)
• Fever (oral temperature >38°C)
• Abnormal chest examination findings (rales, egophony, or tactile fremitus)

If pneumonia IS suspected or confirmed, then antibiotics are indicated. 1

Specific Bacterial Infections Requiring Antibiotics

Bacterial Sinusitis:

If acute bacterial sinusitis is confirmed (persistent symptoms >10 days, severe symptoms with high fever and purulent discharge for 3-4 consecutive days, or worsening after initial improvement): 2

• First-line: High-dose amoxicillin or amoxicillin-clavulanate 2
• Alternatives: Cefuroxime, cefpodoxime, or cefdinir 2
• Penicillin allergy: Clarithromycin or azithromycin 2

Bacterial Bronchiolitis:

Prolonged antibiotic therapy improves cough in bacterial bronchiolitis and is recommended. 1

COPD Exacerbations with Bacterial Infection:

If at least 2 of 3 Anthonisen criteria are present (increased dyspnea, increased sputum volume, increased sputum purulence): 1

• First-line (infrequent exacerbations, FEV1 >35%): Amoxicillin 1
• Second-line (frequent exacerbations ≥4/year or FEV1 <35%): Amoxicillin-clavulanate, cefuroxime-axetil, levofloxacin, or moxifloxacin 1

Community-Acquired Pneumonia:

Antibiotics are recommended in all patients with confirmed pneumonia. 1

• Children <3 years: Amoxicillin 80-100 mg/kg/day in three divided doses 1, 3
• Children >3 years: Amoxicillin for suspected pneumococcal infection; macrolides for suspected atypical pathogens (Mycoplasma, Chlamydophila) 1, 3
• Adults (medical ward): Second or third-generation cephalosporin (cefuroxime, cefotaxime, ceftriaxone) OR benzyl penicillin/amoxicillin OR macrolide 1

Symptomatic Treatment Instead of Antibiotics

For viral cough and congestion, focus on symptomatic relief rather than antibiotics: 1

• Cough suppressants: Dextromethorphan 60 mg (not standard OTC doses of 15-30 mg which are subtherapeutic) 4
• Expectorants: Guaifenesin 1
• First-generation antihistamines: Diphenhydramine (primarily for nocturnal cough) 1, 4
• Decongestants: Phenylephrine 1
• Simple home remedies: Honey and lemon mixtures 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on sputum color alone—purulent sputum does not indicate bacterial infection 1
• Do not use β-agonists (albuterol) unless the patient has asthma or COPD—they don't benefit patients without these conditions 1
• Avoid codeine or pholcodine—they have no greater efficacy than dextromethorphan but significantly more adverse effects (drowsiness, nausea, constipation, physical dependence) 4
• Do not continue antibiotics beyond 3 weeks for persistent cough—reassess for alternative diagnoses like post-viral cough, pertussis, or chronic conditions 4
• Recognize that antibiotics do not treat viral infections including the common cold 5