When should antibiotics be prescribed for upper respiratory tract infections (URTI)?

When to Prescribe Antibiotics for Upper Respiratory Tract Infections

Do not prescribe antibiotics for uncomplicated upper respiratory tract infections in immunocompetent adults, as these infections are predominantly viral and antibiotics do not enhance illness resolution, prevent complications, or reduce symptom duration. 1

General Principles for URTI Management

Most URTIs Are Viral and Self-Limited

• Over 90% of acute URTIs in otherwise healthy patients are caused by viruses and resolve spontaneously within 1-2 weeks. 1, 2
• Symptoms typically improve within the first week without any antibiotic intervention. 1
• Complications such as bacterial rhinosinusitis or bacterial pneumonia are rare. 1

When Antibiotics Are NOT Indicated

• Purulent nasal discharge or sputum (green or yellow) does NOT indicate bacterial infection and should not trigger antibiotic prescription. 1, 2
• Common cold, influenza, COVID-19, and laryngitis should never be treated with antibiotics. 3
• Fever and cough of only 2 days duration without signs of pneumonia requires symptomatic treatment only. 2
• Acute pharyngitis without confirmed Group A Streptococcus does not warrant antibiotics. 1, 3

Specific Conditions Where Antibiotics MAY Be Indicated

Acute Bacterial Rhinosinusitis (ABRS)

Prescribe antibiotics only when meeting strict clinical criteria: 2

• Persistent symptoms without improvement for >10 days, OR
• Severe symptoms (fever ≥39°C, purulent nasal discharge) for ≥3 consecutive days, OR
• "Double worsening" (worsening symptoms after initial improvement)

First-line antibiotic: Amoxicillin or amoxicillin-clavulanate 2, 4

Group A Streptococcal Pharyngitis

• Confirm diagnosis with rapid antigen testing or throat culture before prescribing antibiotics. 1, 2
• Do not prescribe based on clinical findings alone. 5, 6
• Antibiotics reduce symptom duration and prevent complications only when GAS is confirmed. 1

Acute Otitis Media (AOM)

Diagnose only when ALL three criteria are present: 1, 2

• Abrupt onset
• Signs of middle ear effusion
• Symptoms of middle ear inflammation

Immediate antibiotics indicated for: 7, 3

• Children <6 months
• Children 6-23 months with bilateral AOM
• Children >2 years with bilateral AOM and otorrhea
• High-risk patients

Acute Exacerbations of Chronic Bronchitis

Immediate antibiotics NOT recommended for simple chronic bronchitis exacerbation, even with fever. 1, 8

Prescribe antibiotics immediately only if: 1, 8

• Chronic obstructive bronchitis with respiratory insufficiency (dyspnea at rest, FEV1 <35%, hypoxemia), OR
• At least 2 of 3 Anthonisen criteria present:
  • Increased dyspnea
  • Increased sputum volume
  • Increased sputum purulence

First-line antibiotic: Amoxicillin for infrequent exacerbations (≤3/year) with FEV1 ≥35% 1, 8

Clinical Decision Algorithm

Initial Assessment (Day 0-2)

• If fever and cough <2 days duration: Provide symptomatic treatment only 2
• If purulent discharge present: Do NOT prescribe antibiotics based on this alone 1, 2
• If pharyngitis suspected: Perform rapid strep test or throat culture before prescribing 1, 2

Reassessment (Day 2-3)

Clinical follow-up is essential within 2-3 days. 1, 2, 9

Consider antibiotics only if: 1, 2

• Fever >38°C persists for >3 days, OR
• Symptoms worsen after initial improvement, OR
• Specific bacterial infection criteria met (see above)

Red Flags Requiring Immediate Attention

Suspect pneumonia if present: 2

• Tachycardia (heart rate >100 bpm)
• Tachypnea (respiratory rate >24 breaths/min)
• Fever >38°C for >3 days
• Abnormal chest examination findings

Obtain chest radiograph if pneumonia suspected. 2

Antibiotic Selection When Indicated

First-Line Agents

• Amoxicillin for β-lactamase-negative organisms 1, 8, 2, 4
• Amoxicillin-clavulanate for β-lactamase producers or treatment failure 1, 2

Penicillin Allergy Alternatives

• Macrolides, pristinamycin, or doxycycline 1, 8, 2
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) for severe cases 1, 2

Duration of Treatment

• Minimum 7 days for bacterial exacerbations of chronic bronchitis 8
• Follow specific guidelines for other conditions (10 days for streptococcal pharyngitis, etc.) 9

Common Pitfalls to Avoid

Clinical Errors

• Do not diagnose acute sinusitis based solely on purulent discharge - this leads to overdiagnosis and unnecessary antibiotic use. 5
• Do not prescribe antibiotics for "follicular tonsillitis" appearance without confirmed GAS - clinical findings alone are unreliable. 6
• Do not use "early antibiotic treatment" strategies without diagnostic confirmation - this contributes to resistance. 6

Patient Communication

• Patient satisfaction depends more on effective physician-patient communication than on antibiotic prescription. 9
• Explain that antibiotics do not decrease symptom duration or lost work time for viral URTIs. 1
• Emphasize that the number needed to harm (8) exceeds the number needed to treat (18) for acute rhinosinusitis. 2

Symptomatic Treatment Options

Recommend instead of antibiotics for viral URTIs: 2, 9

• Analgesics and antipyretics
• Intranasal saline irrigation
• Intranasal corticosteroids
• Decongestants
• Cough suppressants
• First-generation antihistamines

Consequences of Inappropriate Prescribing

Inappropriate antibiotic use causes: 1, 2

• Avoidable drug-related adverse events
• Development of antibiotic-resistant pathogens (especially antibiotic-resistant S. pneumoniae)
• Increased healthcare costs
• Masking of true infectious disease diagnosis

Previous antibiotic use is the most important factor in carriage of antibiotic-resistant organisms. 1