Guideline Summary for Antibiotic Management of Lower Respiratory Tract Infections

1. Initial Diagnostic Assessment

Suspect pneumonia in a patient with acute cough plus any of the following: new focal chest signs, dyspnea, tachypnea > 24 breaths/min, or fever lasting > 4 days. European Respiratory Society recommendation. 1
Obtain a chest radiograph immediately to confirm or exclude pneumonia, as this determines the therapeutic pathway. European Respiratory Society recommendation. 1
Do not rely on bilateral rhonchi to diagnose pneumonia; radiographic infiltrates are required for confirmation. (Praxis source only – omitted)

Amoxicillin‑clavulanate 625 mg three times daily or 1 g twice daily as monotherapy provides adequate coverage for Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. British Thoracic Society guideline. 5

The regimen also covers Staphylococcus aureus, which is important in cases of treatment failure. British Thoracic Society. 5
It offers β‑lactamase stability against resistant organisms. British Thoracic Society. 5

Use a respiratory fluoroquinolone (levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily) if the patient cannot tolerate amoxicillin‑clavulanate. British Thoracic Society. 5

Do not combine amoxicillin with azithromycin for non‑severe outpatient pneumonia; dual therapy is reserved for severe, hospitalized cases requiring intravenous antibiotics. British Thoracic Society. 5

Routine antibiotics are not recommended for uncomplicated acute bronchitis. (Praxis source only – omitted)
Consider antibiotics only in high‑risk patients with purulent sputum or fever persisting > 4 days. European Respiratory Society. 1

Amoxicillin‑clavulanate 625 mg three times daily or doxycycline 100 mg twice daily for 5 days. European Respiratory Society. 1
Doxycycline is preferred after prior cefixime failure because it covers atypical pathogens. European Respiratory Society. 1
Do not add azithromycin to these regimens; macrolide monotherapy may be used as an alternative, not in combination. European Respiratory Society. 1

Extend therapy beyond 5 days only if there is no clinical response after 72 hours or if complications develop. American Academy of Otolaryngology‑Head and Neck Surgery evidence. 7
If no improvement after 3 days of appropriate antibiotics, repeat chest radiography and consider switching to a respiratory fluoroquinolone. American Academy of Otolaryngology‑Head and Neck Surgery. 7

Dual oral therapy (amoxicillin + azithromycin) for outpatient pneumonia is inappropriate polytherapy and is not guideline‑recommended. British Thoracic Society. 5
Dual therapy should be reserved for severe pneumonia requiring hospitalization. British Thoracic Society. 5

Continue dextromethorphan 10 mg twice daily for bothersome dry cough. European Respiratory Society. 1
Do not prescribe expectorants, mucolytics, or antihistamines for acute lower respiratory infections, as they are ineffective. European Respiratory Society. 1
If wheezing is prominent, a trial of inhaled salbutamol can assess reversible airway obstruction. European Respiratory Society. 1

Reassess the patient 48–72 hours after initiating therapy if symptoms have not improved. American Academy of Otolaryngology‑Head and Neck Surgery. 7
Do not continue ineffective antibiotics beyond 72 hours; instead, switch therapy or reevaluate the diagnosis. American Academy of Otolaryngology‑Head and Neck Surgery. 7

Do not prescribe antibiotics reflexively for all treatment failures; first confirm bacterial infection or pneumonia. European Respiratory Society. 1
Do not overlook non‑infectious causes (e.g., cardiac failure, pulmonary embolism), especially in patients > 55 years old. European Respiratory Society. 1