Antibiotics Are NOT Indicated for Uncomplicated Upper Respiratory Infections
Antibiotics should not be used for uncomplicated viral URIs (common cold, acute rhinopharyngitis), as most URIs are viral in origin and antibiotic treatment provides no benefit while exposing patients to unnecessary harm. 1, 2, 3, 4
When Antibiotics Are NOT Indicated
The following conditions do NOT require antibiotics:
- Common cold/nonspecific URI: Viral etiology; antibiotics do not enhance illness resolution, shorten duration, or prevent pneumonia 1, 3, 5, 4
- Acute rhinopharyngitis: Supportive care only 2, 4
- Influenza: Antiviral agents (not antibiotics) may be considered 3
- COVID-19: Antibiotics have no role unless secondary bacterial infection develops 3
- Laryngitis: Typically viral 3
- Purulent nasal discharge alone: Does not predict bacterial infection or benefit from antibiotics 1, 4
When Antibiotics ARE Indicated: Specific Bacterial Complications
Antibiotics are appropriate only when stringent diagnostic criteria identify specific bacterial URIs 1, 2:
Acute Otitis Media (AOM)
- Diagnostic criteria: Middle ear effusion PLUS signs of inflammation (moderate/severe tympanic membrane bulging, OR mild bulging with ear pain or erythema) 2
- First-line treatment: Amoxicillin 80-90 mg/kg/day divided twice daily 6, 2, 7
- Alternative: High-dose amoxicillin-clavulanate (90 mg/6.4 mg/kg/day) for recent antibiotic exposure or moderate disease 6, 2
- Observation option: Consider for children >2 years with nonsevere, unilateral disease when adequate follow-up is ensured 1, 6, 2
Acute Bacterial Sinusitis
- Diagnostic criteria: URI symptoms that are worsening after initial improvement, severe (high fever ≥39°C with purulent discharge for 3-4 consecutive days), OR persistent beyond 10 days without improvement 1, 6, 2
- First-line treatment: Amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil 1
- Duration: 7-10 days 1
- Observation: May be considered for persistent symptoms only 2
Group A Streptococcal Pharyngitis
- Diagnostic criteria: Test ONLY if ≥2 of the following are present: fever, tonsillar exudate/swelling, tender anterior cervical nodes, absence of cough 2
- Confirmation required: Rapid antigen detection test or throat culture before treatment 2, 8
- First-line treatment: Amoxicillin or penicillin 2
Epiglottitis
- Antibiotics indicated in most cases 3
Critical Pitfalls to Avoid
Do not prescribe antibiotics based on these misleading findings:
- Purulent nasal discharge (present in viral URIs) 1, 4
- Tonsillar enlargement or exudates without confirmed streptococcal infection 8
- Fever alone without meeting specific diagnostic criteria 1
- Patient or family pressure for antibiotics 1
Common prescribing errors:
- Treating before throat culture/rapid antigen test results in suspected strep pharyngitis 8
- Using broad-spectrum antibiotics (macrolides, third-generation cephalosporins) as first-line agents due to high resistance rates 1
- Prescribing azithromycin for AOM or sinusitis (inadequate coverage) 2
Harms of Inappropriate Antibiotic Use
Antibiotics cause substantial harm when used inappropriately:
- Adverse events: Occur in 44% of children receiving high-dose amoxicillin-clavulanate, including diarrhea (most common), rash, vomiting, and abdominal pain 6, 2
- Severe reactions: Stevens-Johnson syndrome, anaphylaxis, sudden cardiac death 1, 2
- Long-term effects: Early-life antibiotic exposure linked to inflammatory bowel disease, obesity, eczema, and asthma 6, 2
- Antibiotic resistance: Individual and community-level resistance develops with inappropriate use 1, 2
- Healthcare costs: Over 150,000 emergency visits annually for antibiotic-related adverse events in children 1
Supportive Care for Viral URIs
Provide the following for uncomplicated viral URIs: