Doctors, get smart and learn about when antibiotics work

Many state health departments – such as the North Carolina Department of Health and Human Services' Division of Public Health – are taking part in the CDC’s national Get Smart: Know When Antibiotics Work campaign, intent on “encouraging the public and healthcare providers to use antibiotics carefully and appropriately to reduce the growth of antibiotic resistance,” the Island Gazette reports. The CDC has established antibiotic prescription guidelines for adults and children seeking care in outpatient settings, as seen below.

Adult treatment recommendations




Acute rhinosinusitis

  • Diagnose acute bacterial rhinosinusitis based on symptoms that are:

-         Severe (>3-4 days), such as a fever ≥39°C (102°F) and purulent nasal discharge or facial pain;

-         Persistent (>10 days) without improvement, such as nasal discharge or daytime cough; or

-         Worsening (3-4 days) such as worsening or new onset fever, daytime cough, or nasal discharge after initial improvement of a viral upper respiratory infections (URI) lasting 5-6 days.

  • Sinus radiographs are not routinely recommended.


If a bacterial infection is established:

  • Watchful waiting is recommended for uncomplicated cases for which reliable follow-up is available.
  • Amoxicillin or amoxicillin/clavulanate is the recommended first-line therapy.
  • Macrolides are not recommended due to high levels of Streptococcus pneumoniae antibiotic resistance.
  • For penicillin-allergic patients, doxycycline or a respiratory fluoroquinolone are recommended as alternatives.


Acute uncomplicated bronchitis

  • Evaluation should focus on discarding pneumonia, which is rare among otherwise healthy adults in the absence of abnormal vital signs and abnormal lung examination findings.
  • Colored sputum does not indicate bacterial infection.
  • For most cases, chest radiography is not indicated.

Routine treatment with antibiotics is not recommended, regardless of cough duration.

Options for symptomatic therapy include:

  • Cough suppressants.
  • First-generation antihistamines.
  • Decongestants.
  • Beta agonists.


Common cold or non-specific upper respiratory tract infection

  • Prominent cold symptoms include fever, cough, rhinorrhea, nasal congestion, postnasal drip, sore throat, headache, and myalgias.
  • Decongestants combined with a first-generation antihistamine may provide short-term symptom relief of nasal symptoms and cough.
  • Non-steroidal anti-inflammatory drugs may relieve symptoms.
  • Evidence is lacking to support antihistamines (as monotherapy), opioids, intranasal corticosteroids, and nasal saline irrigation.


  • Clinical features alone do not distinguish between Group A beta-hemolytic streptococcal (GAS) infections and viral pharyngitis; a rapid antigen detection test (RADT) is necessary to establish a diagnosis.
  • Those who meet two or more Centor criteria (e.g., fever, tonsillar exudates, tender cervical lymphadenopathy, absence of cough) should receive a RADT. Throat cultures are not routinely recommended for adults.
  • Antibiotic treatment is not recommended for patients with negative RADT results.
  • Amoxicillin and penicillin V are the first-line therapy.
  • For penicillin-allergic patients, cephalexin, cefadroxil, clindamycin, or macrolides are recommended.
  • GAS antibiotic resistance to azithromycin and clindamycin is increasingly common.
  • Recommended treatment course for all oral beta lactams is 10 days.

Acute uncomplicated cystitis

  • Symptoms include dysuria, frequent voiding of small volumes, and urinary urgency. Hematuria and suprapubic discomfort are less common.
  • Nitrites and leukocyte esterase are the most accurate indicators.

For acute uncomplicated cystitis in healthy adult non-pregnant, premenopausal women:

  • Nitrofurantoin, trimethoprim/sulfamethoxazole, and fosfomycin are appropriate first-line agents.
  • Fluoroquinolones should be used in situations where other agents are not appropriate.



Pediatric treatment recommendations




Acute rhinosinusitis

Halitosis, fatigue, headache, decreased appetite, but most physical exam findings are non-specific and do not distinguish bacterial from viral causes.

A bacterial diagnosis may be established based on the presence of one of the following:

  • Persistent symptoms without improvement: nasal discharge or daytime cough >10 days.
  • Worsening symptoms: worsening or new onset fever, daytime cough, or nasal discharge after initial improvement of a viral URI.
  • Severe symptoms: fever ≥39°C, purulent nasal discharge for at least 3 consecutive days.

Imaging tests are no longer recommended for uncomplicated cases.

If a bacterial infection is established:

  • Amoxicillin or amoxicillin/clavulanate are the first-line therapy.
  • Recommendations for treatment of children with a history of type I hypersensitivity to penicillin vary.
  • In children who are vomiting or who cannot tolerate oral medication, a single dose of ceftriaxone can be administered.
  • Consult the American Academy of Pediatrics or the Infectious Diseases Society of America guidelines for further recommendations on alternative antibiotic regimens.

Acute otitis media (AOM)

Definitive diagnosis requires either:

  • Moderate or severe bulging of tympanic membrane (TM) or new onset otorrhea not due to otitis externa.
  • Mild bulging of the TM AND recent (<48h) onset of otalgia, or intense erythema of the TM.

AOM should not be diagnosed in children without middle ear effusion (based on pneumatic otoscopy and/or tympanometry).

·         Mild cases with unilateral symptoms in children 6-23 months of age or unilateral or bilateral symptoms in children >2 years may be appropriate for watchful waiting based on shared decision-making.

·         Amoxicillin is the first line therapy for children who have not received amoxicillin in the previous 30 days.

·         Amoxicillin/clavulanate is recommended if amoxicillin has been taken within the past 30 days, if there is concurrent purulent conjunctivitis, or if the child has a history of recurrent AOM unresponsive to amoxicillin.

·         For children with a non-type I hypersensitivity to penicillin, cefdinir, cefuroxime, cefpodoxime, or ceftriaxone may be used.

·         Prophylactic antibiotics are not recommended to reduce the frequency of recurrent AOM.

·         Consult the American Academy of Pediatrics guidelines for further recommendations on alternative antibiotic regimens.


  • Clinical features alone do not distinguish between GAS and viral pharyngitis.
  • Children with sore throat plus 2 or more of the following features should undergo a RADT test:

-         Absence of cough.

-         Presence of tonsillar exudates or swelling.

-         History of fever.

-         Presence of swollen and tender anterior cervical lymph nodes.

-         Age younger than 15 years.

  • Testing should generally not be performed in children younger than 3 years in whom GAS rarely causes pharyngitis and rheumatic fever is uncommon.
  • In children and adolescents, negative RADT tests should be supported by a throat culture.
  • Amoxicillin and penicillin V are the first-line therapy.
  • For children with a non-type I hypersensitivity to penicillin: cephalexin, cefadroxil, clindamycin, clarithromycin, or azithromycin are recommended.
  • For children with an immediate type I hypersensitivity to penicillin: clindamycin, clarithyomycin, or azithroymycin are recommended.
  • Recommended treatment course for all oral beta lactams is 10 days.

Common cold or non-specific upper respiratory tract infection (URI)

  • Viral URIs are characterized by nasal discharge and congestion or cough. Nasal discharge begins as clear and changes throughout the illness.
  • Fever, if present, occurs early in the illness.
  • Management of the common cold, nonspecific URI, and acute cough illness should focus on symptomatic relief. Antibiotics should not be prescribed for these conditions.
  • There is potential for harm and no proven benefit from over-the-counter cough and cold medications in children younger than 6 years.
  • Low-dose inhaled corticosteroids and oral prednisolone do not improve outcomes in non-asthmatic children.


  • Bronchiolitis occurs in children<24 months and is characterized by rhinorrhea, cough, wheezing, tachypnea, and/ or increased respiratory effort.
  • Routine laboratory tests and radiologic studies are not recommended, but a chest x-ray may be warranted in atypical disease.
  • Usually patients worsen between 3 and 5 days, followed by improvement.
  • Antibiotics are not helpful and should not be used.
  • Nasal suctioning is a mainstay of therapy.
  • Albuterol can be trialed but should only be dispensed if there is a documented improvement.
  • Nebulized racemic epinephrine has also shown some benefit.
  • There is no evidence to support routine suctioning of the lower pharynx or larynx.
  • There is no room for corticosteroids, ribavirin, or chest physiotherapy in the treatment of bronchiolitis.

Urinary tract infections (UTIs)

  • In infants, fever and or strong-smelling urine are common.
  • In school-aged children, dysuria, frequency, or urgency are common.
  • A definitive diagnosis requires a urinalysis suggestive of infection and at least 50,000 CFUs/mL of a single uropathogen from urine obtained through catheterization or suprapubic aspiration.
  • Urinalysis is suggestive of infection with the presence of pyuria bacteriuria, or nitrites.
  • Nitrites are not a sensitive measure for UTI in children and cannot be used to rule out UTIs.
  • Urine testing for all children 2-24 months with unexplained fever is no longer recommended.
  • Initial antibiotic treatment should be based on local antimicrobial susceptibility patterns. Suggested agents include TMP/SMX,  amoxicillin/clavulanate, cefixime, cefpodoxime, cefprozil, or cephalexin.
  • Duration of therapy should be 7-14 days.
  • Antibiotic treatment of asymptomatic bacteriuria in children is not recommended.

·         Antibiotic prophylaxis to prevent recurrent UTIs is not recommended.

·         Febrile infants with UTIs should undergo renal and bladder ultrasonography during or following their first UTI. Abnormal imaging results require further testing.


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