Upper respiratory infection
- Common cold, upper respiratory tract infection (URTI), acute rhinitis, acute nasopharyngitis, acute rhinosinusitis
- 460 acute nasopharyngitis (common cold)
- 465.0 acute laryngopharyngitis
- 465.8 acute upper respiratory infections (URIs) of other multiple sites
- 465.9 acute URIs of unspecified site
- Average U.S. adult has two to four colds per year; average schoolchild has 6-10 colds per year.
- URI is second most common diagnosis made at clinician visits (closely following hypertension).
- Usual causative pathogen is rhinovirus or one of many other respiratory viruses.
- Transmitted by particle aerosol and hand contamination (followed by self-inoculation)
- Incubation period: two to four days
Likely risk factors
- Fall and winter
- Exposure to young children (e.g., day care)
- Cigarette smoking
- Psychological stress
- Symptoms: cough, fever, runny or stuffy nose, sore throat, pinkeye, earache, nasal discharge, nasal and pharyngeal erythema or edema, sneezing, sore “scratchy” throat, dry cough, hoarseness, headache, chills, cervical adenopathy
- Purulent rhinitis without unilateral maxillofacial pain may predict “sinusitis” on x-ray, but antibiotics not needed; most such cases are viral.
- May be normal or may reveal findings listed under “History”
- Look for signs of:
- Otitis media: tympanic-membrane bulging, opacified or with limited mobility
- Pneumonia: rales, decreased breath sounds; tachypnea is most telling clinical sign in children.
- Streptococcal pharyngitis: fever, pharyngeal or tonsillar exudate, absence of cough
- Infectious mononucleosis: fever, sore throat, diffuse adenopathy
- Diagnosis of nonspecific URI should be used for acute infection in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent (CDC evidence-based guidelines).
- Clinical judgment not a good predictor of bacterial respiratory infection
- Imaging studies not indicated; radiographic sinusitis is common during the common cold.
- Low nasal swabs are less painful and as accurate as nasopharyngeal swabs in children.
- More than 50% of rhinoviral colds last longer than one week; up to 25% last more than two weeks.
- Complications rare
- Effective symptomatic treatments (supportive therapy)
- Acetaminophen (650 mg p.o. every four hours as needed or 1,000 mg p.o. every six hours as needed) or nonsteroidal anti-inflammatory drugs (NSAIDs):
- For pain, sore throat, symptomatic fever
- Not necessary for asymptomatic fever
- Acetaminophen preferred over NSAIDs
- Decongestants: Limited short-term benefit in adults
- No benefit in young children
- Treatments with limited or inconsistent evidence:
- Some antitussives (dextromethorphan, guaifenesin) in adults
- Ipratropium bromide (Atrovent) nasal spray
- Zinc: zinc gluconate lozenges, zinc acetate lozenges; use of intranasal zinc should be avoided, may lead to permanent loss of smell.
- Echinacea preparations have limited evidence suggesting benefit but insufficient evidence to recommend specific products
- Vitamin C
- Humidifier or vaporizer
- Medications that are not effective
- Antitussives in children
- Intranasal corticosteroids
- Antibiotics not indicated and could be harmful; not necessary for patient satisfaction as long as needs are addressed
- Goldenseal should not be used due to adverse effects and no evidence for efficacy.
- No effective licensed antivirals currently available
- Determining reason for office visit may help determine approach to patient
- If seeking relief, consider symptomatic therapies.
- If seeking reassurance (ruling out serious illness), focus on ruling out pneumonia, strep throat, and otitis media.
- If seeking cure (antibiotics), patient education and delayed prescriptions may be helpful.
- Work or school excuse might be primary reason for visit.
- Receiving information/reassurance more strongly associated with patient satisfaction than receiving antibiotics
- Hand washing
- Associated with 45% reduction in outpatient visits for respiratory illness
- Antibacterial soaps no more effective than plain soap
- Use of instant hand sanitizer associated with reduced illness-related absenteeism among schoolchildren.
- Multivitamin and mineral supplementation
- May reduce incidence of infections in diabetics, based on randomized trial of 158 patients
- Does not reduce incidence of infections in elderly, based on randomized trial of 910 persons and meta-analysis of eight other randomized trials
- Vitamin C prophylaxis
- May modestly reduce duration and severity of common cold
- May prevent common cold during brief periods of severe physical exercise or cold temperature
- Evidence does not support routine use of megadose vitamin C (>1 g/day)
- Evidence inconsistent for effective URI prevention
- Insufficient data to recommend specific preparation
Dr. Alper is editor-in-chief of DynaMed, a database of comprehensive updated summaries covering more than 1,800 clinical topics, and medical director of clinical reference products for EBSCO Publishing, Inc.
See www.dynamicmedical.com for references.