Antibiotics Are Generally NOT Recommended for Upper Respiratory Tract Infections
Most upper respiratory tract infections (URTIs) are viral in origin and do not require antibiotic therapy—antibiotics cause more harm than benefit in these cases. 1, 2 The vast majority of URTIs, including acute rhinopharyngitis, common cold, and nonspecific upper respiratory infections, resolve spontaneously within 2 weeks and should be managed with supportive care alone. 1, 2
When Antibiotics Are Actually Indicated
Antibiotics should only be considered for URTIs when specific bacterial complications develop:
Acute Bacterial Rhinosinusitis (ABRS)
Amoxicillin-clavulanate is the first-line antibiotic when bacterial sinusitis is confirmed by meeting at least one of these criteria: 1
- Symptoms persisting beyond 10 days without improvement 1
- Severe symptoms (fever >39°C with purulent nasal discharge or facial pain) for ≥3 consecutive days 1
- "Double sickening" pattern (worsening after initial improvement) 1
- Unilateral infraorbital pain that increases when bending forward, with pulsatile pain peaking in early evening/night 1
Alternative first-line options include second-generation cephalosporins (cefuroxime-axetil) or third-generation cephalosporins (cefpodoxime-proxetil, cefotiam-hexetil), but NOT cefixime due to inadequate pneumococcal coverage 1
Treatment duration is 7-10 days, though 5-day courses may be effective with certain cephalosporins 1
Streptococcal Pharyngitis
- Penicillin remains the drug of choice for confirmed Group A Streptococcus pharyngitis 3
- Amoxicillin is the first-line treatment, administered twice daily for 10 days 1, 3
- Single-dose benzathine penicillin (parenteral) is also effective 3
Acute Otitis Media (AOM)
- Amoxicillin-clavulanate is first-line treatment when antibiotics are indicated 4, 1
- In children under 2 years, antibiotic therapy is recommended 4
- For children over 2 years, watchful waiting is reasonable unless marked symptoms (high fever, intense earache) are present 4
- Dosing: 80 mg/kg/day in three doses (maximum 3 g/day) for children 1
Critical Pitfalls to Avoid
Do NOT Use First-Generation Cephalosporins
- First-generation cephalosporins (like cephalexin) are explicitly NOT recommended for respiratory tract infections due to inadequate activity against penicillin-resistant S. pneumoniae 1
- This is a common prescribing error—not all cephalosporins are equivalent 1
Do NOT Prescribe Antibiotics for These Presentations
- Purulent nasal secretions alone do not indicate bacterial infection and do not predict benefit from antibiotics 2
- Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotics 4
- Acute bronchitis in otherwise healthy adults, even with fever present 5, 1
Do NOT Use Fluoroquinolones as First-Line
- Ciprofloxacin and ofloxacin lack adequate pneumococcal coverage and should not be used for respiratory infections 4, 1
- Respiratory fluoroquinolones (levofloxacin, moxifloxacin) should be reserved for treatment failures or specific indications, not first-line therapy 1
Recommended Supportive Care Approach
For viral URTIs (the vast majority of cases), provide: 1
- Analgesics for pain relief 1
- Antipyretics for fever management 1
- Saline nasal irrigation 1
- Intranasal corticosteroids for symptom relief 1
- Systemic or topical decongestants as needed 1
When to Reassess for Bacterial Complications
- If fever (>38°C) persists for more than 3 days, reassess for bacterial superinfection 5, 1
- Symptoms persisting beyond 10 days without improvement warrant evaluation for acute bacterial rhinosinusitis 1
- Therapeutic efficacy must be assessed after 2-3 days if antibiotics are initiated 1
- If no improvement occurs within 48-72 hours of antibiotic therapy, clinical and radiological reassessment is necessary 1
Red Flags Requiring Urgent Evaluation
Consider chest radiography and alternative diagnoses if: 6