The false dichotomy of viral versus bacterial aetiology in upper respiratory tract infections

It's time to move away from the viral versus bacterial dichotomy and embrace an evidence‐based syndromic approach

Antimicrobial resistance is a key emerging threat to human health, driven largely by overuse of antibiotics in humans and animals.1 Upper respiratory tract infections (URTIs) are the most common indication for which antibiotics are prescribed in the community,2 despite the fact that antibiotics are of minimal benefit for most of these syndromes. We define URTI broadly to include acute rhinitis, bronchitis, otitis media, pharyngitis and sinusitis. When faced with a patient presenting with symptoms and signs of a URTI, general practitioners face many challenges to antimicrobial stewardship, including patient expectation, but they often frame the problem as “is this viral or bacterial?”. They then base their decision to prescribe antibiotics or not on this distinction. GPs cite diagnostic uncertainty about viral versus bacterial aetiology as a key factor driving their antibiotic prescribing for URTIs.3 Many educational resources aimed both at prescribers and the community refer to the viral versus bacterial paradigm to inform the choice of whether antibiotics should be prescribed or not.