When do you give antibiotics for an Upper Respiratory Infection (URI)?

When to Give Antibiotics for Upper Respiratory Infections

Antibiotics should only be prescribed for URIs when specific bacterial infections are confirmed or highly likely based on stringent diagnostic criteria—most URIs are viral and do not benefit from antibiotics. 1, 2

General Principle: Most URIs Do Not Require Antibiotics

• The vast majority of URIs are viral in origin and antibiotics provide no benefit 1, 3
• Antibiotics should NOT be used for the common cold, influenza, COVID-19, laryngitis, or uncomplicated acute bronchitis 3
• Supportive care with hydration, antipyretics (acetaminophen or ibuprofen), and symptom management is the mainstay of treatment for viral URIs 2, 4

Specific Conditions That May Warrant Antibiotics

Group A Streptococcal (GAS) Pharyngitis

Only prescribe antibiotics after microbiological confirmation:

• Test ONLY if at least 2 of the following are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, OR absence of cough 2, 4
• Use rapid antigen detection test (RAT) or throat culture—do NOT treat empirically based on clinical appearance alone 1, 2
• If RAT is positive, prescribe antibiotics (first-line: amoxicillin or penicillin) 1, 2
• If RAT is negative in low-risk patients, antibiotics are not needed 1

Acute Otitis Media (AOM)

Diagnosis requires BOTH middle ear effusion AND signs of inflammation:

• Moderate/severe bulging of tympanic membrane, OR mild bulging with ear pain or erythema 2, 4
• First-line treatment: amoxicillin 90 mg/kg/day 2, 4
• Consider observation ("wait and see") for uncomplicated cases in children >2 years with reliable follow-up 2
• Use high-dose amoxicillin-clavulanate if antibiotics were given in previous 4-6 weeks 2

Acute Bacterial Sinusitis

Antibiotics indicated only when symptoms are:

• Persistent (>10 days without improvement), OR 2, 5, 3
• Worsening (initial improvement followed by worsening after 5-7 days), OR 6, 3
• Severe (fever >39°C/102.2°F with purulent nasal discharge for at least 3-4 consecutive days) 5
• First-line treatment: amoxicillin with or without clavulanate 1, 2
• Consider observation for persistent symptoms only 2

Epiglottitis

• This is a medical emergency requiring antibiotics 3
• Hospitalization and parenteral antibiotics are indicated 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on clinical appearance alone for pharyngitis—throat cultures or RAT are essential to avoid overtreatment 1, 7
• Do not treat sinusitis with antibiotics before 10 days unless symptoms are severe or worsening 5, 6
• Do not use azithromycin as first-line therapy for pediatric URIs—it has inadequate coverage for common pathogens 2
• Avoid broad-spectrum antibiotics when narrow-spectrum agents like amoxicillin are appropriate 1

Consequences of Inappropriate Antibiotic Use

• Antibiotic-associated adverse events range from diarrhea and rash to life-threatening anaphylaxis and Stevens-Johnson syndrome 2
• Early-life antibiotic exposure may contribute to inflammatory bowel disease, obesity, eczema, and asthma 2
• Inappropriate use drives antibiotic resistance at individual and community levels 1, 2
• Amoxicillin-clavulanate causes more diarrhea than amoxicillin alone 2

Follow-Up Recommendations

• Children treated at home should be reassessed if not improving after 48 hours 2, 4
• Shorter antibiotic courses (7 days vs. 10 days) may be appropriate for older children with AOM 2, 4