Upper respiratory tract infections: the AU antimicrobial stewardship approach

What upper respiratory tract infections actually are

Upper respiratory tract infection (URTI) is the most common reason Australians attend a GP — accounting for approximately 10–15% of all general practice encounters according to the BEACH dataset, with adults averaging 2–4 episodes per year and children 6–10. The term is an umbrella for a cluster of distinct syndromes: common cold, acute pharyngitis and tonsillitis, acute rhinosinusitis, and acute laryngitis.

The central clinical principle, reinforced by eTG and NPS MedicineWise, is that around 80% of URTIs are viral, self-limiting, and resolve without antibiotic treatment. Yet AURA 2023 records Australian antibiotic use at approximately 17.5 defined daily doses per 1,000 people per day — substantially higher than comparable countries like the Netherlands (7.9) — with URTI a major driver. Shifting prescribing culture starts with individual consult decisions.

A. Core clinical — the AU general-practice framework

The sub-syndromes

URTI covers several distinct clinical presentations managed in general practice:

• Common cold (acute viral nasopharyngitis) — rhinorrhoea, sneezing, mild sore throat, mild cough, malaise; peaks at days 2–4; resolves by day 7–10.
• Acute pharyngitis and tonsillitis — sore throat ± fever ± tonsillar exudate ± cervical lymphadenopathy; viral in ~85% of adults, ~70% of children.
• Acute rhinosinusitis — nasal congestion, facial pressure or pain, ± purulent nasal discharge ± fever; viral in approximately 90%.
• Acute laryngitis — hoarseness and voice loss with mild constitutional symptoms.

Acute otitis media (AOM) and croup are related syndromes managed under separate frameworks and are not covered here.

History essentials

Structured history shapes the antibiotic decision. Per RACGP AJGP 2022:

• Symptom cluster — coryza, cough, and sore throat together strongly suggest viral aetiology; isolated sore throat without nasal symptoms increases GAS likelihood.
• Duration and trajectory — typical viral URTI peaks days 2–4, improves by day 7–10; worsening after initial improvement (“double sickening”) raises bacterial sinusitis superinfection.
• ARF risk factors — Aboriginal and Torres Strait Islander identity, Māori, Pacific Islander, refugee from ARF-endemic country, prior ARF or rheumatic heart disease (RHD), household member with ARF/RHD, age 5–20 years, household crowding.
• Red flag inquiry — difficulty swallowing, drooling, trismus (inability to fully open the mouth), muffled “hot potato” voice, severe unilateral throat or ear pain, neck stiffness.

Clinical scoring — Centor and FeverPAIN

Two validated tools help stratify GAS likelihood and guide the throat swab and antibiotic decision:

Centor (1981) awards one point each for: tonsillar exudate, tender anterior cervical adenopathy, absence of cough, and history of fever. The modified McIsaac version adds +1 for age under 15 and −1 for age ≥45.

FeverPAIN (Little, BMJ 2013) awards one point each for: fever in past 24 hours, purulence on tonsils, attendance within three days of onset, severely inflamed tonsils, and no cough or coryza.

Interpretation: score 0–1 → no swab, no antibiotic; score 2–3 → selective swab, antibiotic if positive; score 4–5 → swab and consider empirical treatment in ARF-risk patients.

Symptomatic management for all patients

Per eTG and AMH, symptomatic care is the foundation regardless of aetiology:

• Paracetamol 10–15 mg/kg every 4–6 hours (maximum 4 g/day in adults) for fever and throat pain.
• Ibuprofen 5–10 mg/kg every 6–8 hours — avoid in dehydration, asthma, NSAID sensitivity, CKD, GI ulceration, pregnancy beyond 32 weeks, or age under 3 months.
• Saline nasal spray or irrigation — reduces congestion; safe at all ages.
• Topical decongestants (oxymetazoline, xylometazoline) — short course only, maximum 3 days; longer use causes rebound congestion (rhinitis medicamentosa).
• Honey for cough in children 12 months and older — modest evidence per Cochrane 2018; never in infants under 12 months (botulism risk).
• Rest and hydration.
• Annual influenza and COVID-19 vaccination per current ATAGI schedule — the most effective preventive intervention.

B. Evidence — antimicrobial stewardship and the antibiotic decision

Most sore throats do not need antibiotics

Cochrane systematic review by Spinks (2021) — 29 randomised trials — found antibiotics reduce sore throat duration by approximately 16 hours in standard-risk adults. Suppurative complications (peritonsillar abscess, mastoiditis) are rare in well-resourced healthcare settings and are not substantially prevented by routine antibiotic prescribing for every sore throat.

Harms of unnecessary antibiotics: diarrhoea (including Clostridioides difficile colitis), rash, anaphylaxis, Candida overgrowth, resistance selection, and perpetuating patient expectations that antibiotics are needed for viral illness.

Choosing Wisely Australia and NPS MedicineWise both list unnecessary antibiotic prescribing for URTI as a priority stewardship target. The clinical conversation — explaining why no antibiotic is the right decision — is itself a therapeutic act.

Acute rhinosinusitis — wait at least 10 days

Viral rhinosinusitis is self-resolving in 7–10 days. Per eTG, antibiotics are appropriate only when: symptoms persist for ≥10 days without improvement; symptoms are severe (high fever, intense unilateral facial pain, purulent nasal discharge); or there is “double sickening” — clear clinical worsening after an initial period of improvement.

First-line antibiotic: amoxicillin 500 mg three times daily for 5 days; amoxicillin-clavulanate 875/125 mg twice daily for 5–7 days if recent antibiotic use or treatment failure; doxycycline 100 mg twice daily for 5–7 days in confirmed penicillin allergy.

Intranasal corticosteroids (mometasone, fluticasone, budesonide) provide modest adjunct benefit in moderate-to-severe sinusitis per Cochrane 2013, particularly where allergic rhinitis co-exists.

GAS pharyngitis — when and how to treat

The main indication for antibiotic in pharyngitis is confirmed or strongly suspected GAS infection combined with elevated ARF risk. In standard-risk patients, a positive throat swab with high Centor or FeverPAIN score plus severe symptoms is the usual threshold. In ARF-risk patients, clinical suspicion alone justifies empirical treatment while awaiting the swab.

Per eTG and AMH, first-line antibiotic is phenoxymethylpenicillin 500 mg orally twice daily for adults (15 mg/kg up to 500 mg twice daily for children) for 10 full days — the complete duration is essential for ARF prevention. Partial courses leave residual pharyngeal carriage.

Penicillin allergy alternatives: cefalexin 500 mg twice daily × 10 days (non-immediate allergy); azithromycin 500 mg daily × 5 days, or clarithromycin 500 mg twice daily × 10 days (confirmed penicillin allergy). Avoid amoxicillin when EBV (glandular fever) is in the differential — a non-allergic morbilliform rash occurs in approximately 80–95% of patients with EBV who receive amoxicillin.

C. Acute rheumatic fever — a distinctly Australian clinical priority

Acute rheumatic fever (ARF) is an immune-mediated inflammatory complication of untreated GAS pharyngitis that can cause permanent heart valve damage — rheumatic heart disease (RHD). It primarily affects children and young adults.

RHDAustralia ARF/RHD guideline 3rd edition documents that Aboriginal and Torres Strait Islander Australians have ARF rates approximately 10 times higher than non-Indigenous Australians — among the highest in the world. This disparity is driven by household crowding, geographic access barriers, and high background GAS transmission in affected communities. ARF also affects Pacific Islander, Māori, and refugee populations from endemic regions.

ARF-risk prescribing principles in general practice:

Treat empirically with phenoxymethylpenicillin at any suggestive sore throat presentation — do not wait for the swab result to come back. When adherence to 10-day oral therapy is uncertain, a single intramuscular dose of benzathine benzylpenicillin (BPG) 1.2 million units provides complete coverage without reliance on daily oral dosing — this is the preferred approach in remote settings and where follow-up is difficult, per RHDAustralia.

Once ARF has occurred, the patient requires long-term IM benzathine penicillin prophylaxis (4-weekly injections, typically for years) coordinated with the state RHD register, cardiology, and specialist nursing services.

The ARF-risk population in Australian general practice also includes recent migrants and refugees from Pacific Island nations, parts of South-East Asia, sub-Saharan Africa, and South Asia.

D. Australian operations

Key MBS items:

• Standard GP consultations: items 23 (Level B), 36 (Level C), 44 (Level D).
• Telehealth video and phone equivalents (existing-relationship 12-month rule applies).
• Throat swab MCS: MBS 69300.
• Respiratory multiplex PCR (influenza/COVID-19/RSV): MBS 69494.
• EBV serology: MBS 69384.
• ATSI Health Assessment: MBS 715 (every 9 months; includes ARF/RHD risk screening).

PBS-listed antibiotics:

• Phenoxymethylpenicillin — general schedule.
• Amoxicillin, amoxicillin-clavulanate, cefalexin — general schedule.
• Azithromycin, clarithromycin, roxithromycin, doxycycline — general schedule.
• Benzathine benzylpenicillin (Bicillin LA) — Authority Required (Streamlined) for ARF/RHD secondary prophylaxis; PBS S100 access pathway in remote Aboriginal communities.
• Intranasal corticosteroids (mometasone, fluticasone, budesonide) — general schedule; some available without prescription.

Notifiable diseases — diphtheria, pertussis, measles, mumps, rubella, and invasive group A streptococcal disease (iGAS, now notifiable in most Australian jurisdictions) are reportable to the state Department of Health. Food handlers and healthcare workers with influenza, pertussis, or GAS infection have mandatory work exclusion periods per state public health regulations.

Antibiotic stewardship documentation: note the clinical indication for any antibiotic prescription in the medical record. This satisfies RACGP practice accreditation standards and supports population-level surveillance.

E. Special populations

Children under 5. URTI is the most common childhood illness. Most children require only symptomatic care. Honey for cough is appropriate from 12 months. Topical decongestants are not recommended in children under 6 years. Aspirin is avoided in children under 16 (Reye syndrome risk). ARF predominantly affects children and adolescents in at-risk communities — maintain heightened vigilance.

Pregnancy. Paracetamol remains safe throughout pregnancy. Ibuprofen is avoided after 32 weeks gestation and used cautiously in early pregnancy. Most topical decongestants are generally avoided in the first trimester. Annual influenza vaccination is strongly recommended in pregnancy for both maternal protection and passive infant immunity.

Older adults (≥65 years). Higher risk of URTI complications including bacterial pneumonia and influenza. Annual influenza vaccination and COVID-19 booster per ATAGI are particularly important. Lower threshold for chest auscultation and pulse oximetry. Avoid antihistamines with significant anticholinergic burden.

Immunocompromised patients. URTIs can be prolonged and more likely to progress to bacterial superinfection. Investigations are warranted at lower thresholds. Antibiotic indications are broader. Early liaison with the managing specialist team is appropriate.

ATSI and other ARF-risk patients. As detailed in Section C — empirical GAS treatment at any suggestive sore throat, preferring IM BPG where adherence is uncertain or follow-up cannot be guaranteed. Coordinate long-term prophylaxis with the RHD register and cardiology.

When to escalate

Urgent emergency department referral (with ENT and anaesthetics):

• Epiglottitis — high fever, drooling, tripod position, muffled voice, stridor. Do not examine the throat. Urgent airway management is required.
• Peritonsillar abscess (quinsy) — severe unilateral throat pain, trismus, uvular deviation, “hot potato” voice; requires drainage.
• Retropharyngeal or parapharyngeal abscess — neck stiffness, dysphagia, drooling, especially in young children.
• Lemierre syndrome — post-sore-throat lateral neck swelling with systemic sepsis (Fusobacterium septic internal jugular vein thrombophlebitis).
• Severe sepsis or airway compromise at any stage.

Same-week review: suspected pneumonia not responding, recurrent tonsillitis, persistent symptoms beyond 2 weeks, suspected ARF, fever not resolving after 3 days.

Routine ENT referral: recurrent tonsillitis meeting tonsillectomy criteria (≥7 episodes per year, or ≥5 per year for 2 years, or ≥3 per year for 3 years), chronic rhinosinusitis, suspected immunodeficiency.

What this article is and is not

This is general health information drawn from current Australian general practice guidelines — Therapeutic Guidelines, RACGP AJGP 2022, RHDAustralia ARF/RHD guideline, NPS MedicineWise, and Choosing Wisely Australia. It does not constitute personal medical advice and does not create a doctor–patient relationship. Prescribing decisions, including ARF risk stratification, are made with your own GP based on your complete clinical picture.

For Australian consumer resources: HealthDirect — Common cold, HealthDirect — Sore throat, Better Health Channel — Common cold.

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Sources cited

1. Therapeutic Guidelines — eTG Antibiotic
2. RACGP — Antimicrobials for respiratory infections, AJGP 2022
3. RHDAustralia — ARF/RHD guideline 3rd edition
4. Australian Medicines Handbook
5. NPS MedicineWise — antimicrobial stewardship
6. ACSQHC — AURA 2023
7. Choosing Wisely Australia
8. Royal Children’s Hospital Melbourne — Sore throat
9. HealthDirect — Common cold
10. Better Health Channel — Common cold
11. Centor RM — Med Decis Making 1981
12. Little P (FeverPAIN) — BMJ 2013
13. Spinks A — Cochrane 2021, antibiotics for sore throat
14. Honey for cough — Cochrane 2018
15. Zalmanovici Trestioreanu — Cochrane 2013, intranasal corticosteroids in sinusitis