Antibiotic resistance in upper respiratory tract infections in otorhinolaryngology

Upper respiratory tract infections remain one of the most common reasons for seeking medical care in outpatient practice. Acute rhinosinusitis, pharyngotonsillitis, and acute otitis media occupy a significant place in the structure of otorhinolaryngological diseases and are associated with a high rate of antibiotic prescriptions. At the same time, the majority of acute inflammatory diseases of the upper respiratory tract are of viral origin, which makes the problem of inappropriate antibiotic use particularly relevant. Excessive and irrational administration of antibacterial agents contributes to the development and spread of antimicrobial resistance among key respiratory pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes. The aim of this study was to systematize current evidence on clinically significant manifestations of antibiotic resistance in the most common upper respiratory tract infections encountered in otorhinolaryngological practice. A literature analysis of recent publications indexed in international and Russian scientific databases, including PubMed, the Cochrane Library, and Cyberleninka, was conducted. The review summarizes current approaches to antibiotic prescribing in acute bacterial rhinosinusitis, streptococcal pharyngotonsillitis, and acute otitis media, and discusses patterns of antimicrobial resistance among the main bacterial pathogens responsible for these conditions. In addition, a clinical case of acute otitis media in an adult patient is presented. The case was characterized by the lack of clinical response to initial β-lactam therapy and required microbiological verification of the pathogen followed by adjustment of antimicrobial treatment according to the antibiotic susceptibility profile. The presented data emphasize the importance of rational antibiotic use, microbiological diagnostics, and an individualized therapeutic approach in the management of ENT infections in the context of increasing antimicrobial resistance.

1. Polyakov DP et al. Modern Clinical Guidelines for the Management of Patients with Acute Tonsillitis and Pharyngitis. Pediatric Pharmacology. 2025;22(2):164–177. (In Russ.) https://doi.org/10.15690/pf.v22i2.2897.

2. Kalra MG, Higgins KE, Perez ED. Common Questions About Streptococcal Pharyngitis. Am Fam Physician. 2016;94(1):24–31. Available at: https://pubmed.ncbi.nlm.nih.gov/27386721.

3. Choby BA. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009;79(5):383–390. Available at: https://pubmed.ncbi. nlm.nih.gov/19275067.

4. Low DE. N 298 – Nonpneumococcal StreptoCOccal Infections, Rheumatic Fever. In: Goldman L, Schafer AI (eds.). Goldman’s Cecil Medicine (Twenty Fourth Edition). Saunders; 2012. Vol. 2, pp. 1823–1829. https://doi.org/10.1016/B978-1-4377-1604-7.00298-0.

5. Tatochenko V, Cherkasova E, Kuznetsova T, Sukhorukova D, Bakradze M. Acute Tonsillitis and Bronchitis in Russian Primary Pediatric Care: Prevailing Antibacterial Treatment Tactics and Their Optimization. Am J Ped. 2018;4(3):46–51. https://doi.org/10.11648/j.ajp.20180403.11.

6. Dong L, Jin Y, Dong W, Jiang Y, Li Z, Su K, Yu D. Trends in the incidence and burden of otitis media in children: a global analysis from 1990 to 2021. Eur Arch Otorhinolaryngol. 2025;282(6):2959–2970. https://doi.org/10.1007/s00405-024-09165-z.

7. Ngo CC, Massa HM, Thornton RB, Cripps AW. Predominant Bacteria Detected from the Middle Ear Fluid of Children Experiencing Otitis Media: A Systematic Review. PLoS ONE. 2016;8;11(3):e0150949. https://doi.org/10.1371/journal.pone.0150949.

8. Kozlov RS, Muravyev AA, Scherbakov ME, Rodnikova VY, Romanenko VV, Safianov KN et al. Study to assess incidence of acute otitis media in children under 5 years of age in Russia (PAPIRUS-AOM). Klinicheskaia Mikrobiologiia i Antimikrobnaia Khimioterapiia. 2017;19(2):116–120. (In Russ.) Available at: https://cmac-journal.ru/publication/2017/2/cmac-2017-t19-n2-p116/cmac-2017-t19-n2-p116.pdf.

9. Krivopalov AA, Ryazantsev SV, Shatalov VA. New possibilities of therapy and prevention of complications of infectious-inflammatory diseases of the upper respiratory tract. Meditsinskiy Sovet. 2016;(18):24–32. (In Russ.) https://doi.org/10.21518/2079-701X-2016-18-24-32.

10. Shilenkova VV, Shilenkov KA. EPOS-2020. What’s new? Russian Rhinology. 2020;28(2):94–100. (In Russ.) https://doi.org/10.17116/rosrino20202802194.

11. Fokkens WJ, Lund VJ, Hopkins C, Hellings PW, Kern R, Reitsma S. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology. 2020;58(Suppl. 29):1–464. https://doi.org/10.4193/Rhin20.600.

12. Shivaee A, Kazemi F, Navidifar T, Golab N, Parvizi E, Mofid M et al. Global trends in macrolide and lincosamide resistance in Streptococcus species: a comprehensive systematic review and meta-analysis. BMC Infect Dis. 2025;25(1):1577. https://doi.org/10.1186/s12879-025-11884-5.

13. Arcimowicz M. Rational treatment of acute rhinosinusitis in the context of increasing antibiotic resistance. Otolaryngol Pol. 2024;78(6):1–11. https://doi.org/10.5604/01.3001.0054.7506.

14. Maltsev AB, Mashkova TA, Svistushkin VM, Nikiforova GN, Shevchik EA, Zolotova AV. Features of pathogenetic therapy of infectious and inflammatory diseases of the ENT organs. Meditsinskiy Sovet. 2025;(7):11–16. (In Russ.) https://doi.org/10.21518/ms2025-046.

15. Rapiejko P, Talik P, Jurkiewicz D. New treatment options for acute rhinosinusitis according to EPOS 2020. Otolaryngol Pol. 2022;76(1):29–39. https://doi.org/10.5604/01.3001.0015.7094.

16. Starostina SV, Sivokhin DA. Systemic antibiotic therapy of patients with acute bacterial sinusitis taking into account resistance. Meditsinskiy Sovet. 2021;(18):172–177. (In Russ.) https://doi.org/10.21518/2079-701X-2021-18-172-177.

17. Lopatin AS. Acute rhinosinusitis in EPOS 2020 and updated guidelines of the Russian Rhinologic Society. Pharmacology & Pharmacotherapy. 2022;(S1):30–36. (In Russ.) https://doi.org/10.46393/27132129_2022_S_30.

18. Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev. 2017;(9):CD004417. https://doi.org/10.1002/14651858.CD004417.pub5.

19. Eremeeva KV, Lisenkova DD, Sobolev VP, Sinkov EV. Principles of antibacterial therapy for infections affecting the upper respiratory tract: A clinical case. Meditsinskiy Sovet. 2025;19(7):17–22. (In Russ.) https://doi.org/10.21518/ms2025-060.

20. Cali A, Aslan R, Celik C. Comparison of Antimicrobial Susceptibility Patterns of Streptococcus pneumoniae Respiratory Isolates: Systematic Review and Meta-Analysis. Trop Med Int Health. 2026;31(5):612–622. https://doi.org/10.1111/tmi.70106.

21. Passaris I, Depickère S, Braeye T, Mukovnikova M, Vodolazkaia A, Abels C. Non-invasive Streptococcus pneumoniae infections are associated with different serotypes than invasive infections, Belgium, 2020 to 2023. Euro Surveill. 2024;29(45):2400108. https://doi.org/10.2807/1560-7917.ES.2024.29.45.2400108.

22. Frank T, Wohlfarth E, Claus H, Krone M, Lâm TT, Kresken M. Antibiotic resistance and molecular characterization of non-invasive clinical Haemophilus influenzae isolates in Germany 2019 and 2020. JAC Antimicrob Resist. 2024;6(6):dlae197. https://doi.org/10.1093/jacamr/dlae197.

23. Ling A, Fang L, Liu B, Zhou C, Gong F. Impact of the COVID-19 pandemic on Haemophilus influenzae infections in pediatric patients hospitalized with community acquired pneumonia. Sci Rep. 2024;14(1):12737. https://doi.org/10.1038/s41598-024-62728-2.

24. Zhou M, Fu P, Fang C, Shang S, Hua C, Jing C et al. Antimicrobial resistance of Haemophilus influenzae isolates from pediatric hospitals in Mainland China: Report from the ISPED program, 2017–2019. Indian J Med Microbiol. 2021;39(4):434–438. https://doi.org/10.1016/j.ijmmb.2021.09.001.

25. Starostina SV, Sivokhin DA. Systemic antibiotic therapy of patients with acute bacterial sinusitis taking into account resistance. Meditsinskiy Sovet. 2021;(18):172–177. (In Russ.) https://doi.org/10.21518/2079-701X-2021-18-172-177.

26. Krüger K, Töpfner N, Berner R, Windfuhr J, Oltrogge JH. Clinical Practice Guideline: Sore Throat. Dtsch Arztebl Int. 2021;118(11):188–194. https://doi.org/10.3238/arztebl.m2021.0121.

27. Svistushkin VM, Morozova SV, Kozlova LA. Symptomatic therapy for acute infectious and inflammatory diseases of the pharynx. Meditsinskiy Sovet. 2024;(7):10–14. (In Russ.) https://doi.org/10.21518/ms2024-093.

28. Filippova OV. Acute tonsillopharyngitis: possibilities of combined treatment. RMJ. Medical Review. 2024;8(8):477–483. (In Russ.) Available at: https://www.rmj.ru/articles/otorinolaringologiya/Ostryy_tonzillofaringit_vozmoghnosti_kombinirovannogo_lecheniya.

29. Liang CW, Hsiao MC, Kuo SH, Lin SY, Shih NH, Hsieh MH. Do Hospitalized Adult Patients with Acute Pharyngotonsillitis Need Empiric Antibiotics? The Impact on Antimicrobial Stewardship. Microorganisms. 2025;13(3):628. https://doi.org/10.3390/microorganisms13030628.

30. Biała M, Babicki M, Malchrzak W, Janiak S, Gajowiak D, Żak A et al. Frequency of Group A Streptococcus Infection and Analysis of Antibiotic Use in Patients with Pharyngitis-A Retrospective, Multicenter Study. Pathogens. 2024;13(10):846. https://doi.org/10.3390/pathogens13100846.

31. Linder JA, Watson ME, Wessels MR, Carter DM, Cohen AL, Dien Bard J et al. 2025 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Group A Streptococcal (GAS) Pharyngitis: Risk assessment using clinical scoring systems in children and adults. Clin Infect Dis. 2025:ciaf668. https://doi.org/10.1093/cid/ciaf668.

32. Mustafa Z, Ghaffari M. Diagnostic Methods, Clinical Guidelines, and Antibiotic Treatment for Group A Streptococcal Pharyngitis: A Narrative Review. Front Cell Infect Microbiol. 2020;10:563627. https://doi.org/10.3389/fcimb.2020.563627.

33. S Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;(11):CD000023. https://doi.org/10.1002/14651858.CD000023.pub4.

34. Basit A, Hussain M, Qasim M, Fozia F, Naveed H, Rehman A et al. Prevalence and emm typing of multi-drug resistant Streptococcus pyogenes in tertiary care health settings. BMC Microbiol. 2025;25(1):364. https://doi.org/10.1186/s12866-025-04031-2.

35. El Feghaly RE, Nedved A, Katz SE, Frost HM. New insights into the treatment of acute otitis media. Expert Rev Anti Infect Ther. 2023;21(5):523–534. https://doi.org/10.1080/14787210.2023.2206565.

36. Bursey K, Patey AM, Etchegary H, Aubrey-Bassler K, Kavanagh V, Pike A et al. Barriers and enablers to using evidence-based antibiotic prescription guidelines in primary care: a qualitative systematic review and synthesis using the theoretical domains framework. Implement Sci Commun. 2026;7(1):52. https://doi.org/10.1186/s43058-025-00806-w

37. Katz SE, Jenkins TC, Stein AB, Thomas G, Koenig N, Starnes GL et al. Durations of Antibiotic Treatment for Acute Otitis Media and Variability in Prescribed Durations Across Two Large Academic Health Systems. J Pediatric Infect Dis Soc. 2024;13(9):455–465. https://doi.org/10.1093/jpids/piae073.

38. Grant LR, Apodaca K, Deshpande L, Kimbrough JH, Hayford K, Yan Q et al. Characterization of Streptococcus pneumoniae isolates obtained from the middle ear fluid of US children, 2011–2021. Front Pediatr. 2024;12:1383748. https://doi.org/10.3389/fped.2024.1383748.

39. Dissanayake G, Zergaw M, Elgendy M, Billey A, Saleem A, Zeeshan B, Nassar ST. Effectiveness of Pneumococcal Conjugate Vaccines Over Antibiotic-Resistant Acute Otitis Media in Children: A Systematic Review. Cureus. 2024;16(8):e67771. https://doi.org/10.7759/cureus.67771.

40. Assad Z, Cohen R, Varon E, Levy C, Bechet S, Corrard F et al. Antibiotic Resistance of Haemophilus influenzae in Nasopharyngeal Carriage of Children with Acute Otitis Media and in Middle Ear Fluid from Otorrhea. Antibiotics. 2023;12(11):1605. https://doi.org/10.3390/antibiotics12111605.