Upper respiratory infection

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Also called

  • Common cold, upper respiratory tract infection (URTI), acute rhinitis, acute nasopharyngitis, acute rhinosinusitis

ICD-9 codes

  • 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

Incidence

  • 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).

Etiology

  • 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

History

  • 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.

Physical examination

  • 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

  • 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.

Prognosis

  • More than 50% of rhinoviral colds last longer than one week; up to 25% last more than two weeks.
  • Complications rare

Treatment

  • 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
    • Antihistamines
    • 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

Prevention

  • 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)
  • Echinacea
    • 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.

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