Which upper respiratory infections (URIs) require antibiotic treatment?

Which Upper Respiratory Infections Require Antibiotics

Only three specific bacterial URIs warrant antibiotic treatment in otherwise healthy children: acute otitis media (AOM), acute bacterial sinusitis, and Group A streptococcal (GAS) pharyngitis—and only when stringent diagnostic criteria are met. 1, 2

Conditions That DO Require Antibiotics

Acute Otitis Media (AOM)

Diagnosis requires BOTH middle ear effusion AND signs of inflammation: 1, 2

• Moderate or severe bulging of the tympanic membrane, OR
• Otorrhea not due to otitis externa, OR
• Mild bulging of TM with ear pain or erythema of TM

Treatment approach: 2, 3

• First-line: Amoxicillin 90 mg/kg/day
• High-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) if antibiotics used in previous 4-6 weeks or moderate disease
• Observation ("wait and see") is acceptable for children >2 years with nonsevere symptoms and unilateral disease when adequate follow-up is ensured 1, 2

Acute Bacterial Sinusitis

Diagnosis requires URI symptoms that are worsening, severe, OR persistent: 1, 2

• Worsening: New or worsening fever, daytime cough, or nasal discharge after initial improvement
• Severe: Fever ≥39°C with purulent nasal discharge for ≥3 consecutive days
• Persistent: Nasal discharge or daytime cough >10 days without improvement

Treatment approach: 2, 3, 4

• First-line: Amoxicillin or amoxicillin-clavulanate (45 mg/kg/day standard dose)
• High-dose amoxicillin-clavulanate (90 mg/kg/day) for severe disease or antibiotic resistance risk
• Observation may be considered for persistent symptoms only 2

Group A Streptococcal Pharyngitis

Only test if ≥2 of the following are present: 2, 3

• Fever
• Tonsillar exudate or swelling
• Swollen/tender anterior cervical lymph nodes
• Absence of cough

Treatment approach: 2, 3

• First-line: Amoxicillin or penicillin
• Only treat after confirmation by rapid antigen detection test or throat culture—no empiric treatment 3
• Once-daily dosing of amoxicillin is acceptable 2

Conditions That Do NOT Require Antibiotics

Viral URIs (Common Cold, Nonspecific URI)

Supportive care only: 2, 3

• Adequate hydration
• Fever management with appropriate antipyretics
• Antibiotics provide no benefit and only expose children to potential harm 1
• Review if deteriorating or not improving after 48 hours 2, 3

Critical Pitfalls to Avoid

Inappropriate antibiotic use causes significant harm: 1, 2

• Antibiotics cause >150,000 unplanned medical visits annually for adverse events in children
• Adverse events range from mild (diarrhea 5% increase, rash) to life-threatening (anaphylaxis, sudden cardiac death)
• Amoxicillin-clavulanate causes diarrhea in 44% vs 14% with placebo 1
• Early-life antibiotic exposure may contribute to inflammatory bowel disease, obesity, eczema, and asthma 1

Azithromycin is NOT first-line for any pediatric URI and provides inadequate coverage for common AOM and sinusitis pathogens 1, 2

Macrolides should only be used if Mycoplasma or Chlamydia pneumonia is suspected 2

Key Diagnostic Principle

The fundamental principle is determining the likelihood of bacterial infection before prescribing antibiotics. 1, 3 Most URIs are viral and require only supportive care. 1, 2 Stringent diagnostic criteria must be applied to differentiate bacterial from viral infections, as inappropriate antibiotic use contributes to resistance at both individual and community levels. 1, 2