What are the current guidelines for antibiotic use in Upper Respiratory Tract Infections (URTI)?

Current Guidelines for Antibiotic Use in Upper Respiratory Tract Infections

Antibiotics should NOT be prescribed for uncomplicated viral upper respiratory tract infections, as they are predominantly viral, provide no clinical benefit, do not prevent progression to lower respiratory tract infections, and contribute to antibiotic resistance. 1, 2

Initial Management: Symptomatic Treatment Only

Most URTIs are viral and self-limiting, resolving within 1-3 weeks without antibiotics. 1 The cornerstone of management includes:

• Analgesics/antipyretics (acetaminophen or ibuprofen) for pain, fever, and inflammation 1
• Adequate hydration and rest as supportive measures 1
• Nasal saline irrigation for persistent nasal congestion 1
• Dextromethorphan or codeine for bothersome dry cough 1

Do NOT prescribe:

• Antibiotics for viral URTIs 1, 2
• Mucolytics, expectorants, or bronchodilators (no proven benefit) 1

When Antibiotics ARE Indicated

Acute Bacterial Rhinosinusitis

Antibiotics are indicated when symptoms meet ANY of these criteria:

• Symptoms persist beyond 10 days without improvement 2
• Severe symptoms: fever >39°C with purulent nasal discharge or facial pain for ≥3 consecutive days 2
• "Double sickening" pattern: worsening after initial improvement following typical viral URI 2

First-line treatment:

• Amoxicillin-clavulanate (preferred agent covering penicillin-resistant S. pneumoniae, H. influenzae, and M. catarrhalis) 3, 2
• Alternative options: Second-generation cephalosporins (cefuroxime-axetil) or third-generation cephalosporins (cefpodoxime-proxetil, cefotiam-hexetil, but NOT cefixime) 3, 2
• For beta-lactam allergy: Pristinamycin or macrolides 3
• Duration: 7-10 days (cefuroxime-axetil and cefpodoxime-proxetil effective in 5 days) 3, 2

Important caveat: First-generation cephalosporins (like cephalexin) should NOT be used due to inadequate activity against penicillin-resistant S. pneumoniae. 2

Streptococcal Pharyngitis (Group A Beta-Hemolytic Streptococcus)

• Penicillin remains the drug of choice 4
• Treatment duration: 10 days 1
• Diagnosis must be confirmed by throat culture or rapid antigen detection test before prescribing antibiotics 5

Acute Otitis Media

• First-line: Amoxicillin 80-100 mg/kg/day in three daily doses for children <30 kg 1
• Alternative: Amoxicillin-clavulanate 3

Acute Bronchitis

• No antibiotics needed in otherwise healthy adults, even with fever present 2
• Exception: Consider amoxicillin only if high fever (>38.5°C) persists beyond 3 days with bothersome cough 1

Monitoring and Red Flags

Reassess after 2-3 days of antibiotic treatment to evaluate therapeutic response. 2 Patients should return if:

• Symptoms persist beyond 3 weeks 1
• Fever exceeds 4 days 1
• Dyspnea worsens 1
• Patient's condition deteriorates 1

High-risk patients requiring closer monitoring:

• Age ≥65 years 1
• Chronic cardiac or pulmonary diseases 1
• Diabetes mellitus 1
• Chronic renal diseases 1

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics empirically for viral URTIs—this contributes to antibiotic resistance without clinical benefit 1, 2
• Do NOT use antibiotics to "prevent" lower respiratory tract infections—this approach is proven ineffective 1
• Do NOT assume all cephalosporins are equivalent—second and third-generation agents have significantly better activity against respiratory pathogens than first-generation drugs 2
• Do NOT diagnose acute sinusitis prematurely—overdiagnosis leads to unnecessary antibiotic use 6
• Do NOT prescribe antibiotics for common cold, influenza, COVID-19, or laryngitis 7, 8

Adjunctive Therapies When Antibiotics Are Used

• Intranasal saline irrigation to improve symptom relief and potentially reduce antibiotic duration 2
• Intranasal corticosteroids may enhance outcomes 2
• Analgesics and antipyretics for facial pain and fever 2