The decision whether or not to prescribe antibiotics for patients with upper respiratory tract infections (URTI) is
complex and, as with any primary care decision, is likely to be based on both objective and subjective reasoning.
There has been extensive research on antibiotics in URTI, with a view to reducing inappropriate antibiotic use and,
therefore, the growth of antibiotic resistance. A 2013 Cochrane systematic review concluded that antibiotics were of
no benefit in patients with acute URTI, and were associated with adverse effects.1 However, despite this
research, clinical guidance cannot always be prescriptive because a guidance document will never be able to account
for all the variables present in every clinical contact. Therefore, we rely on clinicians being able to interpret each
individual patient-doctor interaction and come to the most appropriate decision for that patient.
We agree that whenever a patient presents, the problem they have on that day is usually regarded as “significant and
severe” for them. The patient’s perception of their symptoms is very relevant, however, it is the role of the clinician
to objectively evaluate the significance of the patient’s symptoms and signs, while also taking into consideration other
factors such as patient age, relevant past history, social history and the presence of co-morbidities, when formulating
a diagnosis, assessing risk and making treatment decisions. Patients with factors such as a significant past history
of chronic obstructive pulmonary disease (COPD) or bronchiectasis, frail elderly people and those who are immunodeficient
are considered at high risk of complications from URTI.
Clinicians will have a general idea of the usual course of a URTI, based on their experience and observation of other
patients, and can judge if the infection is not resolving in the expected time, or if symptoms are increasing or worsening
in severity. There is clearly a grey area between acute and chronic symptoms, as the latter always begins as the former,
but again, clinical judgement is necessary. Post-infective symptoms such as lingering cough in an otherwise well person
can be differentiated from infection, in which the patient’s signs and symptoms are worsening in severity and they remain
Consensus guidance on appropriate antibiotic use for common infections seen in primary care is available in the updated
Antibiotic Guide accompanying this edition of the journal. We would welcome feedback from clinicians on how they resolve
the “to give an antibiotic or not” dilemma and their strategies on how to balance the benefit and risk for an individual
with the wider goal of reducing inappropriate antibiotic use.