Updated recommendations for the management of upper respiratory tract infections in South Africa

Adrian J Brink, Mark F Cotton, Charles Feldman, Heather Finlayson, Ray L Friedman, Robin Green, Willy Hendson, Maurice H Hockman, Gary Maartens, Shabir A Madhi, Gary Reubenson, Eddie J Silverbauer, Inge L Zietsman

BackgroundInappropriate use of antibiotics for non-severe upper respiratory tract infections (URTIs), most of which are viral, significantly adds to the burden of antibiotic resistance. Since the introduction of pneumococcal conjugate vaccines in 2009 in South Africa, the relative frequency of the major bacterial pathogens causing acute otitis media (AOM) and acute bacterial rhinosinusitis (ABRS) has changed.RecommendationsSince URTIs are mostly viral in aetiology and bacterial AOM and ABRS frequently resolve spontaneously, the guideline includes diagnostic criteria to separate viral from bacterial causes and hence, those patients not requiring antibiotics. Penicillin remains the drug of choice for tonsillopharyngitis. Amoxicillin remains the drug of choice for both AOM and ABRS. A dose of 90 mg/kg/day is recommended for children, which should be effective for pneumococci with high-level penicillin resistance and will also cover most infections with H. influenzae. Amoxicillin-clavulanate (in high-dose amoxicillin formulations available for both children and adults) should be considered initial treatment of choice in patients with recent antibiotic therapy with amoxicillin (previous 30 days) and with resistant H.influenzae infections pending the results of studies of local epidemiology (β-lactamase production ≥15%). The macrolide/azalide class of antibiotics are not recommended routinely for URTIs and are reserved for β-lactam allergic patients. ConclusionThe guideline should facilitate rational antibiotic precribing for URTIs as a component of antibiotic stewardship. However, it requires updating when new information becomes available particularly from randomised controlled trials and surveillance studies of local etiology and antibiotic susceptibility patterns.