What is the primary recommendation for treating bacterial infections, antibiotics or standard treatment (SoT)?

Antibiotics Are the Primary Treatment for Bacterial Infections

For confirmed or suspected bacterial infections, antibiotics are the definitive treatment and should be selected systematically using the WHO AWaRe framework, starting with narrow-spectrum Access group agents as first-line therapy. 1, 2

Evidence-Based Framework for Antibiotic Selection

The WHO established a traffic-light system (AWaRe) specifically to guide every antibiotic prescription, making Access antibiotics the default starting point for empiric therapy of bacterial infections. 2 This framework prioritizes:

• Access group antibiotics (amoxicillin, amoxicillin-clavulanate, cefalexin) as first-choice agents due to their narrow spectrum, favorable benefit-risk ratios, and lower resistance potential 1, 2
• Watch group antibiotics (fluoroquinolones, carbapenems, third-generation cephalosporins) reserved for when Access antibiotics are inadequate or local resistance patterns demand broader coverage 1, 2
• Reserve group antibiotics used exclusively for confirmed or suspected multidrug-resistant organisms 1, 2

Algorithmic Approach to Treatment Selection

Step 1: Identify Infection Site and Likely Pathogens

For common infections, the WHO provides specific first-line recommendations:

• Respiratory tract infections: Amoxicillin or amoxicillin-clavulanate as first choice, with cefalexin, doxycycline, or macrolides as alternatives 2
• Skin and soft tissue infections: Beta-lactams (amoxicillin-clavulanate or cefalexin) for non-purulent infections; dicloxacillin, cefalexin, or clindamycin for impetigo 1, 2
• Sepsis: Amoxicillin + gentamicin, ampicillin + gentamicin, or benzylpenicillin + gentamicin 1
• Urinary tract infections: Access group antibiotics unless local resistance patterns suggest ineffectiveness 1

Step 2: Apply Spectrum Narrowing Principle

Always choose the narrowest spectrum antibiotic that covers likely pathogens. 2 This principle directly combats the 30-50% inappropriate antibiotic prescription rate documented in clinical practice. 2

Step 3: Consider Local Resistance Patterns

Healthcare-associated infections require broader coverage for resistant organisms, while community-acquired infections typically respond to Access group agents. 2 For example, nosocomial pneumonia requires antipseudomonal coverage (cefepime, ceftazidime, piperacillin-tazobactam, or carbapenems). 2

Critical Distinctions from "Standard of Care"

The term "standard treatment" is ambiguous and potentially misleading. Antibiotics ARE the standard of care for bacterial infections—the question is which antibiotic and for how long. 3, 4

Key evidence-based principles:

• Antibiotics should only be used to treat bacterial infections, not viral infections (e.g., common cold) 3
• Treatment duration should be optimized: Shorter courses are as efficacious as longer durations for many infections, including community-acquired pneumonia, ventilator-associated pneumonia, intraabdominal infections, and uncomplicated cystitis 4
• Antibiotic therapy should continue until further debridement is unnecessary, clinical improvement occurs, and fever resolves for 48-72 hours in severe infections like necrotizing soft tissue infections 5

Common Pitfalls to Avoid

Reflexive Broad-Spectrum Prescribing

Avoid defaulting to Watch group antibiotics (fluoroquinolones, carbapenems) when Access group agents are appropriate. 2 Fluoroquinolone overuse is particularly problematic given permanent disabling side effects that can outweigh benefits in routine cases. 2

Inappropriate Treatment of Self-Limited Infections

Otitis media exemplifies high-incidence, low-mortality infections where antibiotics have limited impact on disease evolution and are not indicated in most cases. 5 Inappropriate antibiotic use for self-limiting infections is a major contributor to antimicrobial resistance. 5

Ignoring Treatment Timing

Early optimal treatments tend to be "short and strong," while late optimal treatments tend to be "mild and long." 6 Treatment effectiveness varies significantly with timing along the individual's infection course, not just dose and duration. 6

Monitoring and De-escalation

• Procalcitonin monitoring may guide antimicrobial discontinuation in severe infections like necrotizing soft tissue infections 5
• Culture-specific results should direct both narrowing and broadening of the antimicrobial regimen 5
• Skipping doses or incomplete therapy decreases immediate effectiveness and increases resistance development 3

Special Considerations

Multidrug-Resistant Gram-Negative Bacteria

For third-generation cephalosporin-resistant Enterobacterales and carbapenem-resistant organisms, treatment selection requires careful consideration of individual antibiotics and combination versus monotherapy, with decisions based on all-cause mortality as the primary outcome. 5

Necrotizing Infections

Broad-spectrum empiric coverage for Gram-positive, Gram-negative, and anaerobic organisms is mandatory until culture results are available, with piperacillin-tazobactam appropriate in settings without high ESBL prevalence. 5