Antibiotics in upper respiratory infections: when they help
- Topic
A cold does not need antibiotics; otitis, sinusitis and sore throat need them only when clear criteria are met.
What it is
Deciding well when to give an antibiotic for an upper respiratory infection protects the patient and limits resistance. The WHO names the misuse and overuse of antimicrobials as one of the main drivers of resistance. Using the CDC criteria for adults and children, this page summarises when antibiotics do help in acute otitis media, acute rhinosinusitis and pharyngitis, and why they do not in the common cold. Diagnosis and full treatment of each disease are on its own page.
Key facts
- Acute otitis media: in some mild cases watchful waiting is reasonable with shared decision-making and assured follow-up.
- Amoxicillin is first line in acute otitis media if the child has not received it in the past 30 days.
- Severe sinusitis in children: fever of 39 °C or higher with purulent nasal discharge for at least 3 days in a row.
- Persistent sinusitis in children: observation for up to 3 more days is possible; antibiotics are recommended if the illness is severe or worsening.
- Uncomplicated sinusitis in adults with reliable follow-up: watchful waiting is encouraged; with penicillin allergy, doxycycline or a respiratory fluoroquinolone is used.
- In adults with pharyngitis, throat culture is not routine after a negative rapid test.
- In adults with a cold, a decongestant combined with a first-generation antihistamine may give short-term relief of congestion and cough.
Step by step
- Look for red flags (airway, abscess, orbital or intracranial complication) before thinking about antibiotics.
- Classify the illness: cold, acute otitis media, acute rhinosinusitis or pharyngitis.
- Apply each illness's criterion: eardrum bulging, duration and course of sinusitis, Centor score and rapid test.
- If criteria are not met, explain the expected course and offer symptomatic care.
- If they are met, choose the first-line antibiotic and a defined duration.
- Agree on a review and state which symptoms mean coming back sooner.
When antibiotics help (CDC criteria)
| Illness | Antibiotic when… | First line | Not indicated when… |
|---|---|---|---|
| Common cold | Never for the cold itself | Symptomatic care | Always: it is viral |
| Acute otitis media | Bulging eardrum or new ear discharge, especially with severe symptoms | Amoxicillin | No bulging or discharge (does not meet the diagnosis); mild cases under watchful waiting |
| Acute rhinosinusitis | More than 10 days without improvement, severe illness or worsening | Amoxicillin or amoxicillin with clavulanate | Under 10 days and improving, with no signs of severity |
| Pharyngitis | Group A streptococcus confirmed by rapid test or culture | Penicillin or amoxicillin | Negative rapid test in adults; children under 3 are generally not tested |
In clinical practice
- In adults with a cold there is no evidence supporting antihistamines alone, opioids or intranasal corticosteroids.
- In persistent sinusitis in a child, observation for up to 3 days is a valid option before antibiotics.
- In acute otitis media, a red eardrum alone is not enough for the diagnosis: look for bulging or new discharge.
- In pharyngitis, treating only confirmed streptococcal cases avoids unnecessary antibiotics in viral sore throats.
Next step / Initial management
- Initial workup: otoscopy, throat examination and clinical criteria; rapid streptococcal antigen test when indicated.
- Management: analgesics and antipyretics for all; a first-line antibiotic (amoxicillin or penicillin) only if criteria are met.
- Same-day referral if there is stridor, drooling, trismus, swelling behind the ear or facial palsy.
- Urgent referral if otitis or sinusitis does not respond to treatment or becomes complicated.
- Routine referral to ENT for recurrent otitis or tonsillitis, or persistent sinonasal symptoms.
Test yourself
Think of the answer, then tap the question to see it.
An adult has a sore throat, fever and tonsillar exudate; three Centor criteria are met and the rapid strep test is negative. Is an antibiotic indicated?
No. In adults with a negative rapid test antibiotics are not recommended, and throat culture is not routine.
A child has had a runny nose and daytime cough for 12 days without improvement and no high fever. What are the options according to the CDC?
This meets the criterion for persistent bacterial sinusitis. An antibiotic (amoxicillin with or without clavulanate) can be started or the child observed for up to 3 more days; if worse or severe, treat.
Which otoscopic finding is key to diagnose acute otitis media before prescribing an antibiotic?
Moderate or severe bulging of the tympanic membrane (or new ear discharge not explained by otitis externa). Redness alone is not enough.
Why are antibiotics not given for the common cold?
Because it is a viral infection: the CDC says not to prescribe them and to manage symptoms. Unnecessary use is one of the main drivers of resistance (WHO).
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Outpatient Clinical Care for Pediatric Populations (Antibiotic Prescribing and Use) (Centers for Disease Control and Prevention, 2024); Outpatient Clinical Care for Adults (Antibiotic Prescribing and Use) (Centers for Disease Control and Prevention, 2024); Antimicrobial resistance (fact sheet) (World Health Organization, 2026).
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Representative model, for educational purposes only.