When are antibiotics indicated for a patient with a routine cough and cold?

When to Use Antibiotics for Common Cough and Cold

Do not prescribe antibiotics for routine cough and cold—they provide no benefit, increase adverse effects, and promote antibiotic resistance. 1

Clear Indications: When Antibiotics ARE Appropriate

Antibiotics should be reserved for specific bacterial complications, not the viral illness itself:

Acute Bacterial Rhinosinusitis

Reserve antibiotics for patients meeting one of these three criteria: 1

• Persistent symptoms >10 days without improvement 1
• Severe onset: High fever (>39°C) PLUS purulent nasal discharge or facial pain for ≥3 consecutive days 1
• Double worsening: Initial improvement followed by worsening symptoms after 5 days (biphasic illness pattern) 1

Other Bacterial Complications Requiring Antibiotics

• Pneumonia with infiltrate confirmed on chest radiography 1
• Bordetella pertussis (whooping cough) when diagnosed during an outbreak with high exposure probability 1
• Severe chronic bronchitis in current/former smokers with severe airflow obstruction 1
• Bronchiectasis exacerbations 1

When Antibiotics Are NOT Indicated

Common Cold (Nonspecific Upper Respiratory Infection)

Never prescribe antibiotics—symptoms last up to 2 weeks naturally and antibiotics do not prevent complications. 1

• Antibiotics provide no benefit for symptom duration, work loss, or activity limitation 1, 2
• Adult patients on antibiotics have 3.6 times higher risk of adverse effects compared to placebo 2
• Purulent (green/yellow) nasal discharge alone does NOT indicate bacterial infection—it reflects inflammatory cells from viral infection 1

Acute Bronchitis

Do not prescribe antibiotics regardless of cough duration or sputum color. 1

• Three meta-analyses confirm no impact on illness duration, severity, or complications 1
• Cough typically lasts 10-14 days after the visit—this is normal 1
• Purulent sputum occurs with viral infections and does not indicate bacterial superinfection 1

Acute Cough from Any Viral Upper Respiratory Infection

Antibiotics are not indicated for acute cough from common cold, acute bronchitis, asthma, or mild chronic bronchitis exacerbations. 1

Critical Clinical Decision Point: The First Week Rule

Do not diagnose bacterial sinusitis during the first 7 days of symptoms—viral rhinosinusitis causes identical symptoms and sinus imaging abnormalities. 1

• 87% of patients with recent colds show maxillary sinus abnormalities on CT scan 1
• 79% of these abnormalities resolve spontaneously by days 13-20 without antibiotics, even when air-fluid levels are present 1
• Clinical judgment is required after day 7 to determine if bacterial superinfection has occurred 1

Appropriate Symptomatic Management Instead

For Common Cold

• First-generation antihistamine/decongestant combinations (e.g., brompheniramine with sustained-release pseudoephedrine) provide significant symptom relief 1
• Naproxen reduces cough and cold symptoms 1
• Analgesics and antipyretics for pain and fever 1
• Intranasal ipratropium for rhinorrhea 1
• Zinc lozenges within 24 hours of symptom onset may reduce duration 1

For Acute Bronchitis

• Analgesics, antipyretics for symptom relief 1
• Beta-agonist inhalers if wheezing present 1
• Antitussives for cough suppression 1
• Vaporizers or humidifiers 1

What NOT to Use

• Newer-generation nonsedating antihistamines are ineffective for cold symptoms 1
• Over-the-counter combination cold medications lack proven efficacy in randomized trials 1
• Vitamin C and echinacea have no proven benefit 1

Common Pitfalls to Avoid

Pitfall #1: Prescribing antibiotics to satisfy perceived patient expectations 1

• Patient satisfaction depends on physician-patient communication, NOT receiving an antibiotic 1
• Set realistic expectations: cough lasts 10-14 days after the visit 1
• Use the term "chest cold" rather than "bronchitis" to reduce antibiotic expectations 1

Pitfall #2: Treating purulent sputum or nasal discharge as bacterial infection 1

• Purulence reflects inflammatory cells or sloughed epithelial cells from viral infection 1
• Color alone does not distinguish viral from bacterial etiology 1

Pitfall #3: Diagnosing bacterial sinusitis too early 1

• Wait at least 7-10 days before considering bacterial sinusitis 1
• Look for the specific patterns: persistent >10 days, severe onset, or double worsening 1

Pitfall #4: Using broad-spectrum antibiotics when narrow-spectrum agents are appropriate 1

• When antibiotics ARE indicated (e.g., confirmed bacterial sinusitis), use narrow-spectrum agents like amoxicillin first 3
• Broad-spectrum agents are prescribed at 61% of visits but are rarely necessary 1

Patient Education Points

Educate patients about: 1

• Natural symptom duration (up to 2 weeks) 1
• Antibiotics do not prevent complications like pneumonia or sinusitis 1
• Previous antibiotic use increases risk of antibiotic-resistant infections 1
• Antibiotics have common side effects and rare serious reactions like anaphylaxis 1
• When to return: symptoms worsen or persist beyond 2 weeks 1