No Antibiotic Is Indicated for Uncomplicated Upper Respiratory Infections in Healthy Adults
Antibiotics should not be prescribed for otherwise healthy adults with uncomplicated upper respiratory infections, as these are viral in 98–99.5% of cases and resolve spontaneously within 7–10 days without antimicrobial therapy. 1
Understanding the Diagnosis
Uncomplicated upper respiratory infection (URI) refers to acute viral nasopharyngitis—the common cold—where nasal congestion, rhinorrhea, sore throat, and mild cough are present but none of these symptoms predominates or suggests a specific bacterial complication. 1, 2
The vast majority (>90%) of URIs are caused by rhinoviruses, coronaviruses, adenoviruses, parainfluenza viruses, or respiratory syncytial virus. 3, 4
Purulent nasal discharge or sputum does not indicate bacterial infection; purulence reflects inflammatory cells and sloughed epithelial cells, not bacteria. 1, 2
Why Antibiotics Are Not Recommended
Randomized controlled trials demonstrate that antibiotic treatment of nonspecific URI in adults does not enhance illness resolution and provides no clinical benefit. 1, 2
Antibiotics contribute to adverse events (nausea, diarrhea, rash, allergic reactions), promote antimicrobial resistance, and add unnecessary healthcare costs without improving outcomes. 1, 5
Life-threatening complications of uncomplicated URI are exceedingly rare in immunocompetent adults. 2
Symptomatic Management Is the Standard of Care
Analgesics (acetaminophen or ibuprofen) for pain, headache, and fever control. 3, 6
Oral or topical decongestants (pseudoephedrine or oxymetazoline) for nasal congestion; limit topical agents to ≤3 days to avoid rebound congestion. 3, 7
Antihistamines (first-generation agents such as diphenhydramine) may reduce rhinorrhea and sneezing, though evidence for efficacy is limited. 1
Saline nasal irrigation provides symptomatic relief and helps clear mucus. 3
Adequate hydration and rest support recovery. 3
When to Consider Bacterial Complications (and Therefore Antibiotics)
Antibiotics are indicated only when a specific bacterial complication develops, such as:
Acute Bacterial Rhinosinusitis
Persistent symptoms ≥10 days without improvement (purulent nasal discharge plus obstruction or facial pain/pressure). 1, 8
Severe symptoms ≥3–4 consecutive days with fever ≥39°C, purulent discharge, and facial pain. 1, 8
"Double sickening"—initial improvement followed by worsening after 5–7 days. 1, 8
First-line therapy: amoxicillin-clavulanate 875 mg/125 mg twice daily for 5–10 days. 8
Group A Streptococcal Pharyngitis
Antibiotics are indicated only when rapid antigen detection test or throat culture confirms Streptococcus pyogenes. 1, 7
First-line therapy: penicillin or amoxicillin for 10 days. 4
Acute Otitis Media
Antibiotics are recommended for children <6 months, children 6–23 months with bilateral AOM, and those with otorrhea. 7
In adults, AOM is uncommon; when present, amoxicillin is first-line. 9, 4
Expected Timeline for Symptom Resolution
Nasal congestion and rhinorrhea typically peak at days 2–3 and improve by day 7. 3
Cough may persist for up to 3 weeks even after other symptoms resolve. 1
Patients should follow up only if symptoms worsen or exceed 2 weeks without improvement. 3
Critical Pitfalls to Avoid
Do not prescribe antibiotics based on purulent nasal discharge alone; this is a normal feature of viral URI and does not predict bacterial infection or benefit from antibiotics. 1, 2
Do not prescribe antibiotics for symptom duration <10 days unless the patient meets criteria for acute bacterial sinusitis (severe symptoms ≥3 days or "double sickening"). 1, 8
Do not obtain sinus imaging (X-ray or CT) for uncomplicated URI; up to 87% of viral URIs show sinus abnormalities on imaging, leading to unnecessary antibiotic prescriptions. 8
Avoid fluoroquinolones, macrolides, or broad-spectrum agents for uncomplicated URI; these contribute to resistance without clinical benefit. 1, 5
Patient Education and Shared Decision-Making
Explain that antibiotics will not shorten the duration of symptoms and may cause side effects (diarrhea, rash, yeast infections). 1, 5
Reassure patients that symptom duration of 7–10 days is normal for viral URI and does not indicate treatment failure. 3, 7
Provide clear instructions to return if symptoms worsen, persist beyond 10 days, or if new severe symptoms develop (high fever, severe facial pain, difficulty breathing). 8, 3
Emphasize that symptomatic treatment is the evidence-based standard of care and that "watchful waiting" is appropriate for uncomplicated cases. 1, 2