What is the most appropriate antibiotic for a child with an upper respiratory infection who has an amoxicillin allergy?

Best Antibiotic for Pediatric URI with Amoxicillin Allergy

Most uncomplicated upper respiratory tract infections in children are viral and do not require antibiotics at all—antibiotics should only be prescribed when bacterial infection is confirmed or highly likely based on strict diagnostic criteria. 1

First, Determine if Antibiotics Are Actually Needed

Before selecting an alternative antibiotic, it's critical to establish whether the child truly has a bacterial infection requiring treatment:

• Most URIs are viral and resolve without antibiotics—prescribing antibiotics for viral URIs only exposes children to harm without benefit 1
• For acute otitis media (AOM): requires middle ear effusion AND signs of inflammation (moderate/severe bulging tympanic membrane, otorrhea, or mild bulging with ear pain) 1
• For acute bacterial sinusitis: symptoms must be persistent (>10 days without improvement), severe (fever ≥39°C with purulent discharge for ≥3 days), or worsening after initial improvement 1
• For pharyngitis: only treat if Group A Streptococcus is confirmed by rapid test or culture—do not treat empirically 1

If Antibiotics Are Indicated: Alternative to Amoxicillin

For children with true amoxicillin allergy requiring antibiotic treatment for bacterial URI, the recommended alternatives are cefuroxime-axetil or cefpodoxime-proxetil as first-line options. 1, 2

Specific Recommendations by Condition:

For Acute Bacterial Sinusitis:

• Cefpodoxime-proxetil: 8 mg/kg/day divided into two doses for 7-10 days 1
• Cefuroxime-axetil: effective in 5-day courses 1
• Amoxicillin-clavulanate (80 mg/kg/day in three doses) remains first-line if no allergy 1

For Acute Otitis Media:

• Second-generation cephalosporins (cefuroxime-axetil or cefpodoxime-proxetil) are appropriate alternatives 2
• Treatment duration: 5 days for uncomplicated cases 3, 4

For Streptococcal Pharyngitis:

• If confirmed GAS and penicillin/amoxicillin allergy, macrolides (clarithromycin or azithromycin) may be used 2, 5

Critical Caveats About Alternative Antibiotics

Macrolides and azithromycin are NOT recommended as first-line for most pediatric URIs due to high pneumococcal resistance rates and inappropriate use patterns 1, 4:

• Azithromycin provides inadequate coverage for S. pneumoniae and H. influenzae causing AOM and sinusitis 1
• Macrolide resistance in pneumococci is increasing, limiting effectiveness 2
• Azithromycin has been associated with cardiac risks (QT prolongation) in adults 1

Oral third-generation cephalosporins are generally not recommended for S. pneumoniae infections due to resistance 1

Important Clinical Considerations

• Reassess at 48-72 hours: If no improvement, consider treatment failure and need for alternative therapy or reevaluation 3, 4
• Recent antibiotic exposure (within 4-6 weeks) increases risk of resistant organisms and should guide selection toward broader coverage 3, 4
• Watchful waiting may be appropriate for older children (>2 years) with unilateral AOM and non-severe symptoms rather than immediate antibiotics 1
• Adverse events are common: Even appropriate antibiotics cause diarrhea and rash in ~5% of children, with amoxicillin-clavulanate showing rates up to 44% 1

What NOT to Use

• Avoid fluoroquinolones in children due to potential adverse effects 2
• Avoid aminopenicillins, first-generation cephalosporins, and cotrimoxazole due to high resistance rates 1
• Do not use macrolides for suspected pneumococcal infections (AOM, sinusitis) unless severe beta-lactam allergy 1, 2