Primary-care medicine is as much art as it is science, but clinicians sometimes rely too heavily on the former when it comes to prescribing antibiotics. Nowhere is this truer than in the treatment of respiratory tract infections (RTIs).

Most cases of bronchitis are caused by viruses, but many clinicians prescribe antibiotics at their patients’ insistence. Patients may explain that they are going on a long-planned vacation and just can’t afford to be sick, or they are getting married that weekend and desperately need to get over an annoying cold. After a while, the clinician caves in, prescribes something, and vows this exception will be the last one.

For the first time, there are now data to back up the assertion that when it comes to treating ambulatory viral infections, antibiotics do more harm than good—and that these infections do get better on their own and without specific therapy.

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One of the most surprising findings shows that while there is a 1-in-4,000 chance that an antibiotic will help an acute RTI, there’s a 1-in-1,000 chance that the same prescription will send the patient to the emergency department (ED) with a rash, allergic reaction, or diarrhea. In fact, antibiotics are three times more risky than aspirin, glyburide, or anticonvulsants and cause one fifth of all ED visits for adverse drug events (142,000 visits a year).1

When are antibiotics truly indicated, and when do other treatments suffice? The following discussions—organized by diagnosis—are intended to provide assistance to the busy practitioner who is sorting out the options.

Otitis media

Though not technically part of the respiratory system, the middle ear is infected by the same spectrum of pathogens seen in the upper respiratory tract.

Ear infections are common but rarely serious. Recent years have seen a shift away from automatic prescription of antibiotics to cautious observation in many cases. Current recommendations for treating acute otitis media (OM) include the option to observe a child (without prescribing any antibiotic at all) as long as the ear is not draining, the child is older than age 2 years and otherwise healthy, and he or she has not had OM in the previous three months.

If an antibiotic is used, the drug of choice is still amoxicillin for five to seven days (or 10 days if the patient is younger than two years or if the infection is complicated or recurrent). The correct dose of amoxicillin is 80-90 mg/kg/day.2,3

Secondary choices include a macrolide (erythromycin-sulfisoxazole [Pediazole], azithromycin [Zithromax], or clarithromycin [Biaxin]) or a cephalosporin (cefdinir [Omnicef], cefpodoxime [Vantin], or cefuroxime [Ceftin]). Trimethoprim/sulfamethoxazole (TMP/SMX) is no longer useful in areas with a high percentage of resistant pneumococci.

Antibiotics should not be used to treat middle-ear effusions, however, which tend to resolve spontaneously or are treated by surgical drainage and ventilation.