Most respiratory tract infections are caused by viruses. Bacterial respiratory tract infections are usually treated empirically with antibiotic therapy that targets the most probable causative pathogens. Recommended antibiotic regimens for outpatient treatment of some common respiratory tract infections are listed in Table 1 for adults and Table 2 for children.

The Advisory Committee on Immunization Practices (ACIP) recommends use of certain vaccines in adults residing in the US. Routine childhood immunization has reduced the overall incidence of some of these vaccine-preventable diseases, but many adults remain susceptible. Recommendations for vaccination against COVID-19, seasonal influenza, and monkeypox and vaccination of travelers have been reviewed separately.

More antibiotics are prescribed for treatment of acute otitis media (AOM) than for any other infection in young children. Children with AOM typically present with otalgia, fever, and bulging and erythema of the tympanic membrane.

Treatment of community-acquired pneumonia (CAP) is usually empiric, with selected antibiotic regimens directed against some of the most common causative pathogens. Recommended empiric regimens are listed in Table 2; recommended antibiotic dosages for treatment of CAP are listed in Tables 3 and 4. Joint guidelines for treatment of CAP by the American Thoracic Society and the Infectious Diseases Society of America (ATS/IDSA) were updated in 2019.

This issue includes reviews of drugs for glaucoma, age-related macular degeneration (AMD), bacterial conjunctivitis, and dry eye disease. Allergic conjunctivitis is reviewed in a separate issue.

Lefamulin (Xenleta – Nabriva), a semisynthetic pleuromutilin antibiotic, has been approved by the FDA for IV and oral treatment of community-acquired bacterial pneumonia (CABP) in adults. It is the first systemic pleuromutilin antibiotic to be approved in the US; retapamulin (Altabax), a 1% topical ointment for treatment of impetigo, was approved in 2007.

The FDA has approved omadacycline (Nuzyra – Paratek), a semisynthetic tetracycline derivative, for once-daily IV and oral treatment of community-acquired bacterial pneumonia (CAP) and acute bacterial skin and skin structure infections (ABSSSIs) in adults.

The FDA has warned that use of the macrolide antibiotic clarithromycin (Biaxin, and generics) may increase the risk of cardiovascular morbidity and mortality in patients with heart disease.

View the Expanded Table: Some Vaccines Recommended for Use in Adults

Bacterial infections in adults are generally treated empirically, with the antibiotic covering most, but not all, of the potential causative pathogens. For some infections, culture and sensitivity testing can guide treatment, allowing for use of narrower-spectrum antibiotics. The recommended dosages and durations of antibiotic treatment for common respiratory, skin, and urinary tract infections are listed in Tables 1-3. Infectious disease experts now recommend shorter treatment durations for many infections to reduce the development of antimicrobial resistance and minimize adverse effects.

The FDA has approved Otovel (Arbor), a combination of the fluoroquinolone antibiotic ciprofloxacin 0.3% and the corticosteroid fluocinolone acetonide 0.025%, for otic treatment of acute otitis media with tympanostomy tubes (AOMT) in children ≥6 months old. It is the second fluoroquinolone/corticosteroid combination to be approved for this indication; ciprofloxacin 0.3%/dexamethasone 0.1% (Ciprodex) has been available for many years. In December 2015, a suspension of ciprofloxacin 6% (Otiprio) was approved for otic treatment of bilateral otitis media with effusion in children undergoing tympanostomy tube placement.

The FDA has announced that it is requiring changes in the labeling of systemic fluoroquinolones to warn that the risk of serious adverse effects, including tendinitis, peripheral neuropathy and CNS effects, generally outweighs their benefit for the treatment of acute sinusitis, acute exacerbations of chronic bronchitis, and uncomplicated urinary tract infections. For these infections, the new labels will recommend reserving fluoroquinolones for patients with no other treatment options.

Vaccines recommended for adults residing in the US are reviewed here. Vaccines for travel have been reviewed separately.

Eight vaccines are currently recommended by the US Advisory Committee on Immunization Practices (ACIP) for routine use in adults at various ages...

Rates of meningococcal disease are highest in infancy, but until recently no meningococcal vaccine was approved for use in this age group. MenHibrix (GSK), a new conjugate vaccine that protects against Neisseria meningitidis serogroups C and Y and Haemophilus influenzae type b (Hib), has been approved by the FDA for use in infants ≥6 weeks old and Menveo, a meningococcal vaccine already approved for patients ≥2 years old that protects against serogroups A, C, Y, and W-135, is now approved for use in infants ≥2 months old.

SEROGROUPS — Five major serogroups of N. meningitidis, A, B, C, Y, and W-135, cause most of the reported cases of invasive meningococcal disease. Serogroup A is the leading cause of epidemic meningitis worldwide, especially in the meningitis belt of sub-Saharan Africa, but it is rare in the US. Serogroup B causes about 60% of all meningitis cases in infants and, together with serogroups C and Y, accounts for most of the endemic disease in the US. Serogroup W-135 has caused outbreaks worldwide, particularly among pilgrims to Mecca during the Hajj and their close contacts on arriving home. Serogroup B remains the only major serogroup for which no vaccine is available in the US. A meningococcal B vaccine (Bexsero – Novartis) is licensed in Europe and Australia for patients ≥2 months old.

IMMUNOLOGIC STUDIES — FDA approval of both MenHibrix and Menveo (for this age group) was based on immunologic studies in infants who received the vaccines at 2, 4, 6, and 12 months. Both vaccines produced protective antibody responses in almost all vaccinated infants. With MenHibrix, antibody levels against Hib were non-inferior to those with 2 standard monovalent Hib vaccines.1

RECOMMENDATIONS FOR USE — The CDC’s Advisory Committee on Immunization Practices (ACIP) does not recommend routine vaccination against meningococcal disease for infants. It does recommend use of either MenHibrix or Menveo for infants who are at increased risk of meningococcal disease because of persistent complement deficiencies, functional or anatomic asplenia, or exposure to a community outbreak of disease caused by one of the serogroups in the vaccine.2 Menveo is also recommended for infants traveling with their families to the Hajj or to the meningitis belt of sub-Saharan Africa. Both vaccines can be given on a 4-dose schedule at 2, 4, 6, and 12 months, but the first dose of MenHibrix can be administered as early as 6 weeks and the last dose as late as 18 months.

1. KA Bryant et al. Immunogenicity and safety of H. influenzae type b-N meningitidis C/Y conjugate vaccine in infants. Pediatrics 2011; 127:e1375.

2. AC Cohn et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62(RR-2):1.

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Drugs for glaucoma, age-related macular degeneration, bacterial conjunctivitis, and dry eyes are reviewed here. Drugs for the treatment of allergic conjunctivitis will be reviewed in a future issue of Treatment Guidelines on Drugs for Allergic Disorders.

The FDA has approved ceftaroline fosamil (Teflaro – Forest), an intravenous (IV) cephalosporin, for treatment of acute bacterial skin and skin structure infections, including those caused by methicillin-resistant Staphylococcus aureus (MRSA), and for treatment of community-acquired bacterial pneumonia in adults. It is the first beta-lactam antibiotic approved for treatment of MRSA.

The text below reviews some common bacterial infections and their treatment. The recommendations made here are based on the results of susceptibility studies, clinical trials and the opinions of Medical Letter consultants.

Although immunization programs have produced high vaccination rates in US infants and children, similar successes have not been achieved in adults. Vaccines recommended for routine use in adults are reviewed here. Vaccines for travel are reviewed separately.

Retapamulin (re-tap'-a-mue'-lin; Altabax - Glaxo SmithKline) is a topical antibiotic recently approved by the FDA for treatment of bullous and non-bullous impetigo due to Streptococcus pyogenes and methicillin-susceptible Staphylococcus aureus. It is available as a 1% ointment by prescription only.

Information about empirical treatment of bacterial infections, emerging trends in antimicrobial resistance, new drugs and new data about older drugs continue to become available. Usual pathogens and empiric treatment for some common types of infections are summarized in the text and a table listing the drugs of choice and alternatives for each pathogen begins on page 40. The recommendations made here are based on the results of susceptibility studies, clinical trials and the opinions of Medical Letter consultants.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control (CDC) at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel. Recommendations for the treatment of parasitic diseases are available in the public reading room of The Medical Letter's web site.

New drugs for bacterial infections and new information about older drugs continue to become available. Empirical treatment of some common bacterial infections is discussed in this article. A table listing the drugs of choice and alternatives for each pathogen begins on page 18. These recommendations are based on results of susceptibility studies, clinical trials and the opinions of Medical Letter consultants. Local resistance patterns should be taken into account. Trade names are listed on page 24.

The choice of drugs for treatment of pneumonia depends on the most likely pathogens causing the infection and local antimicrobial resistance patterns. Factors such as severity of illness, presence of co-morbid conditions and whether the infection is community or hospital-acquired also need to be considered.

New drugs for treatment of bacterial infections and new information about older drugs continue to become available. Empirical treatment of some infections is discussed and a table listing the drugs of choice and alternatives for each pathogen are contained in this article. These recommendations are based on results of susceptibility studies, clinical trials and opinions of Medical Letter consultants. Local resistance patterns should be taken into account.

Since The Medical Letter last reviewed the choice of drugs for treatment of bacterial infections, a few new drugs and some new information about older drugs have become available.

The number of immunizations recommended for infants and young children has increased in recent years with the addition of vaccines to prevent Haemophilus influenzae type b infection and hepatitis B (Medical Letter, 33:5, 1991; 34:69, 1992). Now the US Food and Drug Administration has licensed a new vaccine for infants (Tetramune - Lederle-Praxis) that combines a traditional diphtheria, tetanus, and pertussis vaccine (DTP; Tri-Immunol) with a vaccine against Haemophilus influenzae type b (HibTiter).

A new Haemophilus influenzae type b capsular polysaccharide vaccine conjugated with diphtheria toxoid (ProHIBiT - Connaught) was recently marketed in the USA. It is being promoted as a replacement for older, unconjugated H. influenzae vaccines (b- Capsa I; Hibimune; HibVAX) previously reviewed in The Medical Letter (Volume 27, page 61, 1985).