Antibiotic Guidelines for Common Adult Infections in India
General Principles for Indian Context
In India, first-line antibiotic therapy should follow the same evidence-based principles as international guidelines, with amoxicillin (with or without clavulanate) as the cornerstone for most common bacterial infections, while accounting for local resistance patterns and the documented overuse of broad-spectrum agents. 1, 2
The Indian healthcare setting shows concerning trends of increasing "watch category" antibiotic use (second-line agents) and fixed-dose combinations, which should be actively discouraged in favor of narrow-spectrum first-line agents. 3
Acute Bacterial Rhinosinusitis (ABRS)
Initial Management Decision
- Watchful waiting without antibiotics is appropriate for uncomplicated ABRS when follow-up is assured, as 86% of patients improve with placebo by 7-15 days. 4
- Start antibiotics only if symptoms fail to improve after 7 days or worsen at any time. 4
First-Line Antibiotic Choice
- Prescribe amoxicillin with or without clavulanate for 5-10 days as first-line therapy for most adults. 4
- Plain amoxicillin is sufficient for uncomplicated cases without risk factors. 4
- Use amoxicillin-clavulanate when β-lactamase-producing organisms are suspected or in patients with chronic lung disease. 4
Treatment Failure Management
- Reassess at 7 days if no improvement to confirm diagnosis and exclude complications. 4
- If initially observed without antibiotics, start antibiotic therapy. 4
- If already on antibiotics, change to a different agent. 4
Community-Acquired Lower Respiratory Tract Infection (LRTI)
First-Line Antibiotic Selection
- Amoxicillin 500-1000 mg every 8 hours is the first-choice antibiotic for uncomplicated LRTI managed at home in adults without risk factors. 1, 2
- Treatment duration should be 5-7 days. 1, 2
Risk-Based Escalation to Amoxicillin-Clavulanate
Switch to amoxicillin-clavulanate when any of these risk factors are present: 1, 2
- High local prevalence of β-lactamase-producing Haemophilus influenzae
- Chronic lung disease (COPD, bronchiectasis)
- Recent antibiotic exposure
- Documented failure of plain aminopenicillin therapy
Alternative Agents (for penicillin allergy)
- Macrolides (clarithromycin 250-500 mg twice daily) 2
- Tetracyclines (doxycycline 100 mg twice daily) - particularly suitable for smokers 2
- Oral cephalosporins for non-anaphylactic penicillin allergy 2
- Fluoroquinolones reserved only for treatment failures or complicated cases 2
Critical Pitfall to Avoid
- Do not use cefuroxime as automatic first-line in patients with chronic lung disease or recent antibiotic exposure; amoxicillin-clavulanate is superior for these scenarios. 1
- Avoid oral cephalosporins when β-lactamase-producing organisms are suspected. 1
Hospital Referral Criteria
Refer immediately if any of these signs are present: 2
- Respiratory rate ≥30 breaths/min
- Temperature <35°C or ≥40°C
- Heart rate ≥125 beats/min
- Blood pressure <90/60 mmHg
- Cyanosis
- Altered mental status or confusion
Follow-Up Expectations
- Reassess if fever persists beyond 48 hours after starting therapy. 1, 2
- Inform patients that cough may persist longer than the antibiotic course—this does not indicate treatment failure. 1, 2
Bacterial Tracheitis (Outpatient)
First-Line Therapy
- Amoxicillin or amoxicillin-clavulanate for 5-7 days is recommended for outpatient bacterial tracheitis without complicating factors. 5
- Use amoxicillin-clavulanate for patients with chronic lung disease or risk factors for β-lactamase-producing organisms. 5
Alternative Options
- Macrolides (azithromycin) or tetracyclines (doxycycline) for penicillin-allergic patients. 5
- Oral cephalosporins for non-anaphylactic penicillin allergy. 5
- Respiratory fluoroquinolones reserved for treatment failures. 5
Complicated Urinary Tract Infections (cUTI)
Risk Assessment and Culture Requirements
- All patients with cUTI require urinalysis plus culture and sensitivity testing before treatment, as etiology and susceptibility are unpredictable. 6
- Screen for complicating factors: anatomic/functional abnormalities, recent hospitalization, recent antibiotic use, severe underlying disease. 7, 6
Empiric Therapy Selection
For mild lower cUTI without risk factors for resistance: 6
- Fluoroquinolones (if local resistance <10%)
- Trimethoprim-sulfamethoxazole
- Nitrofurantoin (lower tract only)
For serious cUTI with risk factors for resistant organisms: 6, 8
- Broad-spectrum agents required: carbapenems or piperacillin-tazobactam
- Do NOT use fluoroquinolones as first-line if patient has recent fluoroquinolone exposure or risk factors for resistance
Treatment Duration
- Ranges from 1-4 weeks based on clinical situation and response. 6
- De-escalate to narrow-spectrum therapy once susceptibilities are known. 6
Key Principles for the Indian Context
Combat Overuse of Broad-Spectrum Agents
- Indian hospitals show increasing prescribing of "watch category" antibiotics (second-line agents) and fixed-dose combinations between 2008-2017. 3
- Only 40-61% of prescriptions comprised "access category" antibiotics (first-choice agents). 3
- Actively prescribe access antibiotics (amoxicillin, plain penicillins) as first-line to reverse this trend. 3
Avoid Fixed-Dose Combinations
- FDC prescribing was significantly higher (18%) in non-teaching hospitals and increased over time. 3
- Use single-agent therapy whenever possible to reduce adverse effects and resistance. 3
Implement Local Guidelines
- Local prescribing guidelines and diagnostic routines can improve prescribing practices in Indian settings. 3
- Base empiric therapy on local resistance patterns while defaulting to narrow-spectrum agents when appropriate. 6, 8