Introduction

Upper respiratory tract infection (URTI) accounts for a large proportion of acute presentations in children.1 The diagnostic labels available to clinicians (eg, tonsillitis and otitis media) are ill-defined, and evidence suggests a poor correlation between individual signs and symptoms and the differentiation between viral and bacterial infection.2

The role of antibiotics in the absence of invasive infection or complications is unclear. Symptom benefit has been shown to be poor in tonsillitis and otitis media. The perceived role of preventing complications is questionable following a dramatic reduction in the rates of suppurative (eg, mastoiditis) and non-suppurative (eg, rheumatic fever) complications of URTI over the past half-century.3

UK National Institute for health and Care Excellence (NICE) guidelines have advocated the use of decision tools (FeverPAIN) and a variety of strategies to maximise the possibility of symptom benefit from antibiotics, however minimal the benefit may be.4 While NICE guidelines do not address the issue of using antibiotics to prevent complications by allowing clinician and patient/parent choice to be a factor, the implication is that antibiotics are never mandated purely for the purposes of the prevention of complications.

The lack of clarity regarding the use of antibiotics for URTI (including tonsillitis and otitis media) has led to a large variation in clinical practice. This article explores another approach and the applicability of this in the UK: one of avoiding antibiotic use in low-risk children who have no evidence of invasive infections or complications, directing antibiotic treatment to children who are high risk or have signs of complications. The validity of this approach has become more relevant in the climate of the COVID-19 pandemic, where clinicians would benefit from a more straightforward model.