When Children Actually Need Antibiotics — and When They Don't

Viral vs. bacterial — why it matters

Most upper respiratory infections in children — runny nose, cough, mild sore throat, congestion — are caused by viruses. Antibiotics do nothing to shorten these illnesses, and giving them when they are not needed carries real downsides: disruption to the child's gut microbiome, possible side effects such as diarrhea or rash (occurring in up to 1 in 5 children who take antibiotics), and contribution to antibiotic resistance in the community 1Ref 1American Academy of Pediatrics (2022).Antibiotics for Children: 10 Common Questions Answered.Antibiotics treat bacteria not viruses; color of nasal discharge does not indicate antibiotics needed; side effects in up to 1 in 5 children; do not give leftover antibiotics; viral infections do not benefit from antibiotics2Ref 2Centers for Disease Control and Prevention (2024).Outpatient Clinical Care for Pediatric Populations.Antibiotics not indicated for colds, non-specific URI, bronchiolitis; watchful waiting for mild acute otitis media; confirmation testing required for strep and UTI before prescribing.

Bacterial infections that do benefit from antibiotics include confirmed strep throat, certain ear infections (acute otitis media), urinary tract infections, and some pneumonias 2Ref 2Centers for Disease Control and Prevention (2024).Outpatient Clinical Care for Pediatric Populations.Antibiotics not indicated for colds, non-specific URI, bronchiolitis; watchful waiting for mild acute otitis media; confirmation testing required for strep and UTI before prescribing. The distinction often requires an exam and sometimes a rapid test — yellow or green nasal discharge, for example, is still most often viral and is not by itself a reason to prescribe 1Ref 1American Academy of Pediatrics (2022).Antibiotics for Children: 10 Common Questions Answered.Antibiotics treat bacteria not viruses; color of nasal discharge does not indicate antibiotics needed; side effects in up to 1 in 5 children; do not give leftover antibiotics; viral infections do not benefit from antibiotics.

Common infections that usually do NOT require antibiotics

The following are caused by viruses and do not benefit from antibiotics 1Ref 1American Academy of Pediatrics (2022).Antibiotics for Children: 10 Common Questions Answered.Antibiotics treat bacteria not viruses; color of nasal discharge does not indicate antibiotics needed; side effects in up to 1 in 5 children; do not give leftover antibiotics; viral infections do not benefit from antibiotics2Ref 2Centers for Disease Control and Prevention (2024).Outpatient Clinical Care for Pediatric Populations.Antibiotics not indicated for colds, non-specific URI, bronchiolitis; watchful waiting for mild acute otitis media; confirmation testing required for strep and UTI before prescribing:

• The common cold / upper respiratory infections — the most frequent reason children visit a doctor; almost always viral
• Most sore throats — viral tonsillitis is far more common than strep; only a positive swab indicates antibiotics
• Bronchiolitis — the chest virus common in infants; antibiotics are not helpful
• Influenza — treated with antivirals (in some cases), not antibiotics
• RSV — supportive care; no antibiotic role
• Most cases of conjunctivitis (pink eye) — viral conjunctivitis does not require antibiotic drops

A runny nose that turns yellow or green after a few days is still usually viral — color change alone does not indicate bacteria 1Ref 1American Academy of Pediatrics (2022).Antibiotics for Children: 10 Common Questions Answered.Antibiotics treat bacteria not viruses; color of nasal discharge does not indicate antibiotics needed; side effects in up to 1 in 5 children; do not give leftover antibiotics; viral infections do not benefit from antibiotics.

Infections where antibiotics are often appropriate

Strep throat — confirmed by a rapid swab or throat culture — is treated with antibiotics to shorten illness and prevent rheumatic fever 3Ref 3Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C (2012).Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.Strep throat as a confirmed bacterial indication for antibiotics; penicillin/amoxicillin as first-line; rheumatic fever prevention as primary rationale.

Urinary tract infections in children are bacterial and require antibiotics.

Acute otitis media (middle ear infection) is sometimes treated with antibiotics, though guidelines recognize that children over 2 years with mild cases may be watched for 48–72 hours before prescribing — a 'watchful waiting' approach 2Ref 2Centers for Disease Control and Prevention (2024).Outpatient Clinical Care for Pediatric Populations.Antibiotics not indicated for colds, non-specific URI, bronchiolitis; watchful waiting for mild acute otitis media; confirmation testing required for strep and UTI before prescribing.

Pertussis (whooping cough) and some cases of bacterial pneumonia are also treated with antibiotics. A provider makes the determination based on the child's age, severity of symptoms, and examination findings.

What to expect at the appointment

A provider who does not prescribe antibiotics at an illness visit is making an evidence-based decision, not a dismissive one. Parents can ask: 'Is this more likely viral or bacterial?' and 'What should I watch for that would change that assessment?' 1Ref 1American Academy of Pediatrics (2022).Antibiotics for Children: 10 Common Questions Answered.Antibiotics treat bacteria not viruses; color of nasal discharge does not indicate antibiotics needed; side effects in up to 1 in 5 children; do not give leftover antibiotics; viral infections do not benefit from antibiotics

Many practices use a watchful waiting approach for mild ear infections in older children, with a prescription provided to fill only if the child is not better in 48–72 hours. Clear discharge instructions and a plan for follow-up matter more than the prescription itself. Good handwashing and keeping children current on vaccinations (including flu and pneumococcal vaccines) remain the most effective tools for preventing many of these infections.