A 9-year-old child weighing ~40 kg with a viral upper respiratory infection (common cold) and cough was started empirically on clarithromycin; should the antibiotic be continued and what is the appropriate management?

Management of Common Cold with Cough in a 9-Year-Old: Discontinue Clarithromycin Immediately

The clarithromycin should be discontinued immediately—antibiotics are not indicated for the common cold, nonspecific upper respiratory infection, or acute cough illness in children, as they provide no benefit and expose the child to unnecessary harm. 1

Why Antibiotics Should Not Be Used

The American Academy of Pediatrics explicitly states that antibiotics should not be prescribed for common cold, nonspecific URI, acute cough illness, and acute bronchitis—management should focus solely on symptomatic relief. 1 The FDA drug label for clarithromycin confirms it should only be used to treat bacterial infections and does not treat viral infections like the common cold. 2

Key Evidence Against Antibiotic Use:

• Antibiotics are not effective for viral respiratory infections and lead to significantly increased risk for adverse effects including abdominal pain, diarrhea, rash, Clostridium difficile colitis, and development of antibiotic resistance 1
• Even acute bronchitis, which is prescribed antibiotics over 70% of the time in practice, should never receive antibiotics 1
• The number needed to harm from antibiotics often exceeds any potential benefit in viral respiratory infections 1

Appropriate Management Strategy

Symptomatic Treatment Options:

• For cough relief in this 9-year-old: Honey is first-line treatment (1-2 teaspoons as needed), which provides more relief than diphenhydramine or placebo 3
• Adequate hydration and rest are foundational supportive measures 3
• Analgesics/antipyretics (acetaminophen or ibuprofen) may be offered for pain or fever 1
• Nasal saline irrigation can provide symptomatic relief for congestion 1

What NOT to Use:

• Over-the-counter cough and cold medications should be avoided in children under 4-5 years, but even in older children, dextromethorphan is no more effective than placebo 3
• Antihistamines provide no benefit for cough relief and are associated with adverse events 3
• Codeine-containing medications are contraindicated due to risk of serious respiratory complications 3

When to Consider Antibiotics (Bacterial Complications Only)

Antibiotics are only indicated if bacterial complications develop—not for the viral cold itself. 3 Reassess for these specific conditions:

Acute Bacterial Sinusitis Criteria:

• Persistent symptoms: Nasal discharge (any quality) or daytime cough not improving by 10 days 1
• Worsening symptoms: New or worsening fever, daytime cough, or nasal discharge after initial improvement of typical viral URI 1
• Severe symptoms: Fever ≥39°C AND purulent nasal discharge for at least 3 consecutive days 1

Acute Otitis Media:

• Requires middle ear effusion AND signs of inflammation (moderate/severe bulging of tympanic membrane, otorrhea not due to otitis externa, or mild bulging with ear pain) 1

Streptococcal Pharyngitis:

• Requires confirmation by rapid testing or culture—only test if at least 2 of the following: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, absence of cough 1
• Do not treat empirically without testing 1

Follow-Up Instructions

Expected Timeline:

• Common cold symptoms typically last up to 2 weeks 1
• Advise parents to follow up if symptoms worsen or exceed expected recovery time 1, 3

Red Flags Requiring Immediate Re-evaluation:

• Respiratory distress: respiratory rate >50 breaths/min in this age group, grunting, intercostal retractions 3
• Oxygen saturation <92% 3
• Poor feeding, altered mental status, or difficulty breathing 3
• Development of high fever (≥39°C) with purulent discharge lasting ≥3 days 1

Common Pitfalls to Avoid

• Do not continue antibiotics due to parental pressure despite lack of efficacy for viral infections 3
• Do not assume that starting antibiotics prevents bacterial complications—antibiotics play no role in preventing complications like sinusitis, asthma exacerbation, or otitis media from the common cold 1
• Do not fail to educate parents that the common cold is viral and self-limited, and that antibiotics increase harm without benefit 3
• Do not prescribe "just in case"—this contributes to antibiotic resistance and exposes the child to unnecessary adverse effects 1, 2