eMedicine Specialties > Pulmonology > Infectious Lung Diseases

Upper Respiratory Tract Infection: Follow-up

Author: Anne Meneghetti, MD, Assistant Professor of Medicine, Tufts University School of Medicine; Medical Broadcaster, Life, Love and Health
Contributor Information and Disclosures

Updated: Aug 12, 2009

Follow-up

Further Inpatient Care

In most immunocompetent patients with URIs who require hospitalization, the infection resolves within several days. Reduction in the following parameters signals resolution:

• Tachypnea
• Tachycardia
• Use of accessory muscles of respiration
• WBC abnormalities
• Hypoxemia
• Fever

Further Outpatient Care

Symptomatic self-care

Nasal and sinus symptom relief

Several home care measures may help.

• Warm moist air: Nasal and paranasal sinus mucosae may become more irritated with dry air. The following strategies may maintain the moisture of membranes and loosen nasal secretions: 
  • Turn on hot shower water, close the bathroom door, sit down, and inhale the steam. Take long steam showers.
  • Use a vaporizer to increase humidity in rooms. The water must be changed daily to prevent microbial growth, especially with heated vaporizers. Heated systems may pose a risk for scalding injuries.
  • Pour boiled water into a shallow pan or bowl placed in a stable location (eg, middle of a kitchen counter). Patients can drape a cloth over their head and lean over the bowl to inhale the steam. Exercise caution to avoid spilling boiling water, which may cause scalding injuries.
  • Sipping hot water or warm drinks may be more soothing to the nasal passages than ice cold drinks.
  • Avoid extremely cool and dry air.
• Nasal saline: This may provide temporary relief of congestion by removing nasal crusts and dried secretions. A systematic review of nasal saline irrigation as an adjunct for chronic rhinosinusitis symptom management concluded that evidence shows symptom relief and that irrigation is well tolerated by most patients.³¹ Patients with sinusitis experienced symptomatic benefit from use of a neti pot method of nasal irrigation.³² Saline drops or sprays are commercially available. A homemade normal saline solution can be prepared by placing a fourth of a teaspoon of table salt in 8 oz. of water. A bulb syringe, dropper, clean pump spray bottle, or squeeze bottle can be used to instill the saline into each nostril while the person inhales and then expels the saline. Saline is safe to use as needed.
• Hydration: Drinking 8 or more 8-oz glasses of water, juice, or noncaffeinated beverages daily may help thin mucus secretions and replace fluid losses. Patients with congestive heart failure or renal or liver disease may need to moderate their fluid intake to avoid volume excess.
• Warm facial packs: These may provide comfort, relieve congestion, and promote drainage in cases of rhinosinusitis. A warm folded washcloth or hot-water bottle (filled with hot water from a tap) may be applied directly to the face and cheek for 5-10 minutes. Facial packs may be repeated 3-4 times a day as needed.
• Bulb suction: For infants, a bulb syringe can be used to gently suction the nostrils before feeding to ease nasal breathing. Parents should clean the bulb after each use with hot soapy water followed by a rinse. Drain the bulb and allow it to dry before reuse.
• Irritant avoidance: Patients should avoid nasal irritants, such as cigarette smoke and indoor and outdoor air pollutants.

Throat symptom relief

Warm saline gargles may reduce edema associated with a sore throat. Using lozenges, eating popsicles, or drinking cold and slushy beverages may soothe a sore throat. Avoid choking hazards in small children.

Cough relief

Reduce irritating stimuli (eg, cold, dry air; indoor or outdoor air pollutants) that may provoke coughing. An upright or semiupright posture, such as sleeping with the head and shoulders raised, may decrease cough related to pharyngeal secretions. A 2007 study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI.²⁸

Sleep

Sleeping with the head and shoulders slightly elevated may promote sinus and nasal drainage. Many symptoms worsen at night because airway clearance mechanics are relatively ineffective in the prone position. In addition, distractions from the experience of symptoms are fewer than during the day. Under normal circumstances, the 2 nares alternate between being open or closed throughout the day. Cycles last approximately 45-90 minutes per nares. When the person is lying recumbent on one side, the nares closest to the pillow or surface tends to become congested while the higher nostril is decongested. During nasal congestion associated with URI, alternating positions or lying with the shoulders and head propped up may increase comfort.

Follow-up care

Patients with URI should follow up with a physician if their symptoms do not improve, if their symptoms worsen within 72 hours, or if they have recurrences.

Follow-up testing is not routinely necessary in cases of group A streptococcal pharyngitis that resolve. However, follow-up may be advisable in the setting of recurrent group A streptococcal disease, rheumatic fever, poststreptococcal glomerulonephritis, or outbreaks in semiclosed environments.³³

In general, relapse of group A streptococcal disease may be treated with the same regimen as before or with a different one. In cases of relapse, determine if adherence to previous therapy was sufficient. If adherence to oral therapy is a concern, consider a single injection of benzathine penicillin in patients not allergic to penicillin.

Chronic carriers of group A streptococcal organisms whose symptoms resolve do not require further antibiotic therapy. Eradicating the pathogen is difficult in these cases. However, carriers without active symptoms are unlikely to spread group A streptococci, and they are at low risk for developing rheumatic fever.³⁴

Mononucleosis

Patients with infectious mononucleosis should be instructed to follow up with their physician after a week.

Diphtheria

Elimination of the organism should be documented with 2 consecutive negative culture results after the completion of therapy.¹³

Inpatient & Outpatient Medications

Symptom-based therapy represents the mainstay of URI treatment in immunocompetent adults. Antimicrobials are used in selected circumstances.

Group A streptococcal disease

Recognizing group A streptococcal disease is important because, untreated, it may lead to acute rheumatic fever (ARF) . Because group A streptococcal disease is difficult to distinguish from the more common viral pharyngeal infection, antigen-detection tests and throat culture are useful in guiding therapy. Beginning treatment before positive results are confirmed is not ideal because therapy is often inadvertently continued even if the results are negative.

Oral penicillin for 10 days is recommended for group A streptococcal pharyngitis in patients without an allergy to penicillin. No group A streptococci are resistant to penicillin, and this treatment is effective for both treating pharyngitis and for preventing ARF.³⁵ Macrolides may be appropriate in patients with penicillin allergy. If compliance with oral therapy is a concern, consider a single intramuscular injection of benzathine penicillin G. For patients with recurrent or complicated group A streptococcal infections, cephalosporins may be appropriate.

The following features suggest group A streptococci disease¹⁵ :

• Personal history of rheumatic fever (especially carditis or valvular disease) or a household contact with a history of rheumatic fever
• Erythema, swelling, or exudates of tonsils or pharynx
• Tender anterior cervical nodes (1 cm or larger)
• Absence of cough, rhinorrhea, and conjunctivitis (common with viral illnesses)
• Fever with a temperature of at least 38.3°C (100.9°F) in the preceding 24 hours
• Patient aged 5-15 years
• November-May season

Rhinosinusitis

Acute maxillary and ethmoid bacterial rhinosinusitis in immunocompetent adults diagnosed in the outpatient setting is most often related to uncomplicated viral URIs. Most cases of acute rhinosinusitis, including mild and moderate cases of bacterial sinusitis, resolve without antibiotics.³⁶ Data from controlled trials suggest that more than half of adults and children improve within 3-10 days of treatment with placebo; however, amoxicillin increased the percentage of those with improvement at both time points.¹⁶

Antibiotic treatment may be appropriate when symptoms of rhinosinusitis last 7 days or longer and when maxillary face pain or teeth tenderness (especially when unilateral) is present with purulent nasal secretions and fever. Therapy may also be appropriate for patients with severe symptoms, especially unilateral face pain, even when the symptoms have not lasted 7 days.³⁷

Treatment should begin with an agent that most narrowly covers likely pathogens, including S pneumoniae, nontypeable H influenzae, and M catarrhalis. If no clinical improvement of moderate-to-severe cases is evident within 2-3 days after antibiotics are started, consider an antibiotic with a broader spectrum than the one used previously. One option is amoxicillin-clavulanate, a second-generation cephalosporin, or a newer-generation macrolide.

Cefdinir, cefuroxime, or cefpodoxime may be considered in patients with amoxicillin allergy (but not a type 1 allergic reaction). In patients with serious amoxicillin allergy, a newer-generation macrolide or clindamycin may be appropriate. Amoxicillin-clavulanate or a cephalosporin may be appropriate in persons whose condition does not respond within 72 hours.³⁸

Antibiotics are typically continued for 7 days after symptoms begin to improve or resolve, and 10- to 14-day courses are typical.

Selected other conditions warranting consideration of antibiotics

Epiglottitis

Empiric coverage for H influenzae is appropriate. Systemic antibiotic therapy should begin after blood cultures (and epiglottic cultures, if laryngoscopy is performed) are taken. Common choices for drug therapy include ceftriaxone, cefuroxime, cefamandole, or third-generation cephalosporins. After culture and sensitivity results are available, therapy may be further tailored. Close contacts should receive prophylactic oral therapy (see Deterrence/Prevention).

Whooping cough or pertussis

This infection warrants treatment with a macrolide antibiotic. Close contacts should receive prophylactic treatment (see Deterrence/Prevention).

Diphtheria

Diphtheria warrants treatment with a macrolide or penicillin. Diphtheria antitoxin may neutralize circulating (unbound) toxin. Sensitivity testing is required before antitoxin is used. The US Centers for Disease Control and Prevention (CDC) provides guidance on availability and use of this antitoxin.

Influenza

For treatment options in seasonal influenza, see the eMedicine article Influenza. The CDC tests circulating influenza viruses for resistance patterns to antiviral medications and issues treatment guideline updates each influenza season.³⁹ For recommendations on the 2009 H1N1 influenza (swine flu) outbreak, see the eMedicine article on H1N1 influenza.

Immunocompromise

Immunocompromised patients with certain URIs are at risk for progression to lower respiratory tract and systemic disease. Although antivirals do not generally play a role in most cases of upper respiratory tract disease, consider available treatment options for HSV pharyngitis, RSV infection, and cytomegaloviral infection in immunocompromised patients. HSV infection may be treated with acyclovir, famciclovir, or valacyclovir. For cytomegalovirus infections, consider foscarnet or ganciclovir. RSV infections may respond to ribavirin. If lower respiratory tract disease is evident, these considerations become more compelling than for isolated URI.

HSV infection or gonococcal pharyngitis

Specific therapies are available for gonococcal and HSV pharyngitis. Gonococcal pharyngitis may be difficult to eradicate. Gonococcal therapy is typically a single intramuscular dose of ceftriaxone or a single oral dose of ciprofloxacin. Coincident chlamydial pharyngitis is unusual. However, if chlamydial infection is not ruled out, a single dose of oral azithromycin or a 1-week course of oral doxycycline may be added.¹⁹ Alternate antibiotics may be appropriate during pregnancy. HSV pharyngitis may be treated with high-dose acyclovir. Valacyclovir and famciclovir may also be used.

Symptom-based therapy

Treatment of uncomplicated URI is focused on specific measures to reduce symptoms.

Sneezing, rhinorrhea, and nasal congestion

• Oral decongestants: These agents may provide symptom relief for those with persistent rhinorrhea or sneezing associated with URI. However, despite common usage, evidence regarding the effectiveness of oral decongestants in acute sinusitis is scarce.
  • Adverse effects include anxiousness, insomnia, tachycardia, elevated blood pressure, palpitations, tremor, and urinary retention. Exercise caution in patients with heart disease, hypertension, prostate enlargement, glaucoma, anxiety, hyperthyroidism, or other medical conditions and pregnant or lactating women. Unlike topical nasal decongestants, oral decongestants do not appear to cause rebound phenomena after cessation of use.
  • The risk-to-benefit ratio for using cough and cold medicines in children younger than 2 years requires careful consideration because serious adverse events, including fatalities, have been reported with the use over-the-counter preparations.²⁹ Numerous over-the-counter cough and cold preparations are labeled "do not use" in children younger than 4 years.³⁰
• Topical decongestants: Agents such as phenylephrine and oxymetazoline, a selective alpha2-adrenergic agonist, may provide rapid temporary relief of nasal obstruction. However, these agents may be associated with rebound congestion after cessation of use. To avoid this rebound congestion, limit topical agents to 3-4 days of use. Data from one study suggested that oxymetazoline did not accelerate the rate of healing of acute maxillary sinusitis, as judged by sinus radiographs and subjective symptom scores.⁴⁰ These decongestants may cause throat irritation in some individuals.
• Ipratropium bromide: An anticholinergic, ipratropium bromide has been evaluated in adults and young adults with rhinorrhea of moderate or greater severity. In one study, ipratropium reduced the severity of sneezing and rhinorrhea, but it did not appear to reduce nasal congestion. Rates of blood-tinged mucous and nasal dryness were higher in the treated group than in the control group.⁴¹
• Antihistamines: Histamines are not thought to play a role in generating URI symptoms; therefore, newer nonsedating antihistamines are not useful in reducing URI symptoms. However, first-generation oral antihistamines (eg, diphenhydramine, chlorpheniramine, clemastine) have some anticholinergic effects, which, in theory, could reduce sneezing and rhinorrhea. Clemastine fumarate, a first-generation antihistamine, reportedly reduces rhinorrhea and sneezing associated with the common cold.⁴² However, older antihistamines are sedating. In nonallergic children with acute bacterial rhinosinusitis, data regarding the efficacy of H1 blockers as adjuvants to antibiotics are insufficient.³⁸ In theory, antihistamines may thicken secretions and thus reduce sinus drainage.
• Topical and systemic steroids: These agents are often prescribed with the intention of reducing mucosal swelling in patients with acute viral or bacterial rhinosinusitis. However, little evidence supports their use for this indication. In children who are taking antibiotics for acute bacterial rhinosinusitis, intranasal steroids do not appear to dramatically improve symptoms.³⁸ However, for adults with recurrent acute rhinosinusitis or acute rhinosinusitis superimposed on chronic rhinosinusitis, adjunctive high-dose nasal corticosteroids may decrease symptom duration and improve clinical success rates.^15,43
• Saline nasal drops: Drops may provide relief from thick secretions and mobilize nasal crusting. Nasal saline irrigation is effective and well tolerated as an adjunct to persistent rhinosinusitis symptoms.³¹
• Guaifenesin: A mucolytic, guaifenesin is commonly suggested with the intention of thinning secretions. However, data regarding its effectiveness in reducing secretions and in promoting drainage in persons with nasopharyngitis or rhinosinusitis are limited.
• Phenol: Lozenges, gargles, or sprays that contain phenol may provide temporary relief of sore throat. In young children, lozenges may pose a choking hazard. Gargles of viscous lidocaine may numb the throat, providing relief; however, swallowing may be impaired if sensation is reduced. Saline gargles may reduce swelling in individuals with pharyngitis.
• Cromolyn: Data are insufficient to permit evidence-based recommendations regarding the use of intranasal cromolyn sodium to treat URI-related nasal symptoms in nonallergic patients.

Cough relief

Cough suppression may increase comfort when cough is severe or when it prevents sleep. The following agents may reduce cough in the setting of a URI.²⁶ The risk-to-benefit ratio for using cough and cold medicines in children younger than 2 years requires careful consideration because serious adverse events, including fatalities, have been reported with the use over-the-counter preparations in young children.²⁹ Since 2008, many nonprescription cough and cold product labels state "do not use" in children younger than 4 years.³⁰

• Antihistamine and decongestants: Cough associated with the common cold may be treated with a first-generation antihistamine combined with a decongestant (eg, brompheniramine with pseudoephedrine). Older-generation histamines have anticholinergic effects, which may account for cough reduction. Newer-generation (nonsedating) antihistamines are ineffective for cough.
• Inhaled ipratropium: An anticholinergic, inhaled ipratropium may be useful in postinfectious cough (3-8 wk after the onset of the URI) in adults.
• Inhaled steroids: These agents may be considered in postinfectious cough (3-8 wks after URI onset), if ipratropium fails to control the cough. If postinfectious cough remains severe and if other causes (eg, rhinosinusitis, cough asthma, gastroesophageal reflux disease) have been excluded, a short time-limited course of oral steroids may be considered.
• Dextromethorphan: This is a centrally acting cough suppressant and it may be considered for the treatment of postinfectious cough in adults if other medications fail. However, dextromethorphan may have limited efficacy in treating cough related to acute URI. A 2007 study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI.²⁸ Over-the-counter cough suppressants may cause notable adverse effects in young children. Additional data are required to permit evidence-based recommendations for the use of central-acting antitussives in URI-related cough in children.⁴⁴
• Codeine: This agent is an effective centrally acting cough suppressant in adults. As with other centrally acting antitussives, additional evidence is required to tailor evidence-based recommendations for the use of codeine in URI-related cough in children.⁴⁴ Clinically significant respiratory and nonrespiratory adverse events have been reported. Sedatives should be avoided in patients with chronic obstructive pulmonary disease and in others at risk of respiratory depression.
• Peripherally acting cough suppressants: While these medications may have a role in bronchitis, they may have limited efficacy in relieving cough associated with URI.
• Guaifenesin: As an expectorant, guaifenesin is intended to mobilize secretions. However, consistent data regarding its effectiveness in reducing discomfort from cough associated with URIs are scarce.
• Long-acting inhaled beta-agonists: Beta-agonists are not thought to be helpful in URI-related cough, including that due to pertussis. However, beta-agonists are recommended in the setting of cough asthma and asthma or chronic obstructive pulmonary disease exacerbated by URI.
• Nonsteroidal anti-inflammatory drugs: They may be used to reduce discomfort due to cough. Avoid aspirin in children with viral illness because aspirin is associated with Reye syndrome.
• Cromolyn: Data are insufficient to permit evidence-based recommendations regarding the use of inhaled cromolyn sodium to treat URI-related cough in patients without asthma.

Fever and discomfort relief

• Antipyretics: Fever may be physiologically helpful in eliminating pathogens from the body. However, in some individuals, fever poses a risk of provoking underlying illness. For example, in a fragile cardiac patient, increased metabolic demands associated with fever may increase the work of the heart. In children with a history of febrile seizures, avoiding high fevers may reduce the risk of seizure. Acetaminophen, rather than aspirin, is recommended for pediatric patients because aspirin is associated with Reye syndrome.
• Analgesics: Sore throat, myalgias, face pain, and other sensations often accompany URI. Acetaminophen, rather than aspirin, is recommended for pediatric patients because aspirin is associated with Reye syndrome. Avoid the use of respiratory depressants in patients with serious airway congestion or compromise.

See Further Outpatient Care for home care symptom relief recommendations.

Complementary and alternative therapies

Alternative therapies and traditional folk remedies are widely used to treat URIs. While some might provide symptomatic relief, current studies are insufficient to permit evidence-based conclusions regarding effectiveness.

Zinc

Studies of oral zinc have yielded mixed results, and data on children are limited. Unpleasant taste and nausea have been reported. Zinc nasal gel has been studied for the common cold.⁴⁵ However, the US Food and Drug Administration (FDA) has received reports of long-lasting or permanent loss of smell associated with the use of intranasal zinc; in some cases, anosmia occurred with the first dose; in others, it occurred after multiple uses of intranasal zinc.

On June 16, 2009, the FDA issued a public health advisory and notified consumers and health care providers to discontinue use of intranasal zinc products. The intranasal zinc products (Zicam Nasal Gel/Nasal Swab products by Matrixx Initiatives) are herbal cold remedies that claim to reduce the duration and severity of cold symptoms and are sold without a prescription. The FDA received more than 130 reports of anosmia (inability to detect odors) associated with intranasal zinc. Many of the reports described the loss of smell with the first dose.⁴⁶

Echinacea

When taken at the onset of URI symptoms in children aged 2-11 years, echinacea did not seem to reduce the duration or severity of symptoms compared with placebo. Some children had a rash in response to taking echinacea.⁴⁷

Vitamin C

High-dose oral vitamin C supplementation for the attenuation of URI symptoms has been studied. Results have been inconsistent.

Traditional folk remedies

Some include sipping hot water with a teaspoon of honey and fresh lime or lemon juice. Honey should not be given to infants because of their inability to easily digest spores commonly contained in honey. A 2007 study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI.²⁸ Teas made from demulcent herbs are traditionally used to soothe sore throats. Such herbs include slippery elm bark (Ulmus rubra), marshmallow root (Althea officinalis), and licorice root (Glycyrrhiza glabra). One study of 60 adults revealed a temporary favorable trend in improving symptoms of pharyngitis when they drank a tea containing these herbs compared with placebo.⁴⁸ Prolonged, excessive use of licorice, another folk remedy, may affect potassium levels and volume status.

Deterrence/Prevention

Reducing susceptibility

• Breastfeeding: The practice of breastfeeding transfers protective antibodies through the mother's milk to newborns, passively immunizing babies to numerous pathogens.
• Smoking: Stopping smoking and reducing exposure to second-hand smoke may reduce the incidence of URI.
• Nutrition: Adequate nutrition is required for overall health and optimal immune function. Eating 5 servings of fruits and vegetables each day is commonly recommended. Various vitamins and minerals are necessary for immunity. Obtaining nutrients from food may have more nutritional benefit than taking individual supplements.
• Exercise: Moderate exercise may result in positive, transient changes in immune function.⁴⁹
• Stress: Stress has deleterious effects on the immune system. Measures to reduce stress may include changing schedules and responsibilities, increasing time spent doing relaxing activities, and increasing sleep time.

Preventing the spread of infection

• Handwashing: This is the mainstay for reducing the risk of contracting a URI. Wash the hands for 20 seconds with ordinary soap and water; include all surfaces of the hands, such as in between the fingers and around the nail bed where debris may accumulate. People should wash their hands before eating and preparing meals, after toileting, after changing diapers or handling other waste, and after coughing or sneezing. Especially during cold season, people should wash their hands frequently and avoid touching unwashed hands to their nose and mouth. Use of alcohol-based hand sanitizers is acceptable when soap and water are not available. Avoid contact with secretions of infected persons. Cover coughs and sneezes with a tissue or upper sleeve.
• Cleaning: Rhinoviruses can survive for as long as 3 hours on skin and fomites, such as telephones, door handles, and stair railings. Regular cleaning of environmental surfaces with a disinfectant may reduce the spread of infection; however, optimal cleaning approaches have not been established.
• Contacts: Patients with URI should reduce contact with others to avoid the spread of infection. Adults may be infectious from the day before symptoms begin through approximately 5 days after the onset of illness. Children may shed virus for several days before their illness begins, and they may remain infectious for up to 10 days after symptom onset. Patients with whooping cough or pertussis may be contagious for weeks during the coughing phase. Severely immunocompromised persons may shed virus for weeks or even months. Patients with diphtheria should be isolated. For recommendations regarding contacts of confirmed or suspected H1N1-infected patients, see the eMedicine article H1N1 Influenza (Swine Flu).
• Preventing spread of group A streptococcal infection: Patients with group A strep confirmed with culture or rapid antigen testing should not attend daycare, school, or work for 24 hours after antibiotics are started. After 24 hours of antibiotic treatment, an infected person is not generally able to spread the bacteria. Asymptomatic household contacts of patients with group A streptococcal pharyngitis do not generally require throat culture or rapid antigen testing. However, in the setting of recurrent group A streptococcal disease, rheumatic fever, poststreptococcal glomerulonephritis, or outbreaks in semiclosed environments, testing and treating household contacts who are positive for group A streptococci may be advisable.³³
• Preventing spread of epiglottitis: Consider rifampin prophylaxis for close contacts of a patient with epiglottitis, especially when unvaccinated young children are among the contacts.
• Preventing spread of pertussis: Patients with whooping cough, or pertussis, should be isolated for 5 days to reduce the spread of infection. All close contacts should receive an antibiotic active against pertussis, such as azithromycin, erythromycin, or trimethoprim-sulfamethoxazole, regardless of their age or vaccination status. All close contacts younger than 7 years who have not received the complete 4-dose primary vaccination series should finish the series with minimal intervals between doses. Close contacts aged 4–6 years who have not yet received the second booster dose should be vaccinated.⁵⁰
• Preventing spread of diphtheria: Diphtheria is not usually contagious 48 hours after antibiotics are started, although isolation is warranted until that time. Household contacts or other close contacts should receive benzathine penicillin or a 7- to 10-day course of oral erythromycin and an age-appropriate diphtheria booster.⁵⁰
• Orogenitally transmitted infections: These infections, such as HSV infection and gonorrhea, warrant evaluation of contacts to reduce the spread of infection. Partners who have had genital or orogenital contact with an N gonorrhoeae– infected patient should be evaluated and treated for N gonorrhoeae and Chlamydia trachomatis. This recommendation applies to partners whose last genital or orogenital contact was within 60 days before the patient's onset of symptoms or diagnosis. Patients should avoid having intercourse until therapy is completed and until both patients and their partners no longer have symptoms.⁵¹ Patients with HSV pharyngitis should be counseled about the spread of infection, and their contacts should be evaluated.

Immunization and immunoprophylaxis

• Diphtheria and pertussis: Immunization against diphtheria and pertussis is recommended for nonimmunized patients. To address the increased rate of pertussis cases in adolescents whose immunity has waned, the American Academy of Pediatrics recommends that adolescents receive a single dose of the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap). In 2006, the CDC Advisory Council on Immunization Practices (ACIP) recommended that adults aged 19-64 years receive Tdap as a replacement for the tetanus and diphtheria (Td) booster. Adults younger than 65 years who have contact with infants can help protect infants by receiving Tdap. Health care personnel and women who might become pregnant are also encouraged to receive Tdap.⁵⁰
• Hib: This vaccination has dramatically reduced rates of epiglottitis.
• RSV passive immunoprophylaxis: This may be given as a monthly administration of anti-RSV immunoglobulin or monoclonal antibody to reduce the risk of lower respiratory tract disease and of hospitalization in infants and children at high risk for RSV disease. These high-risk patients include premature infants and children younger than 2 years with bronchopulmonary dysplasia. Prophylaxis is also considered for infants and young children with hemodynamically significant congenital heart disease.
• Influenza vaccination: This is recommended in certain groups. Chemoprevention is available for influenza; however, it does not replace vaccination. For treatment options, see the eMedicine article Influenza. See also the CDC Web page, What You Should Know About the Flu.

Prevention with complementary and alternative therapies

Complementary and alternative therapies and folk remedies are used by some to prevent URIs. Common choices include zinc, echinacea preparations, and vitamin C. However, conclusive evidence that these strategies reduce URI infection is inconsistent. Lactobacillus GG is being studied for a possible connection in reducing the incidence of respiratory infections.

Complications

General complications

Most URIs are self-limited and resolve completely. However, several conditions may complicate an URI:

• Volume depletion: Fluid loss may occur in patients unable to tolerate adequate oral intake because of upper airway inflammation and in those with increased losses from fever.
• Otitis media: This may complicate 5% of colds in children and up to 2% of colds in adults.⁵²
• Airway hyperreactivity: It may increase after a URI, resulting in new or exacerbated asthma. Cough asthma, wherein a dry cough is the predominant manifestation of reactive airways disease, may mimic ongoing infection. This may be diagnosed with pulmonary function testing. A postinfectious cough is defined as coughing that persists 3-8 weeks after the onset of a URI in the absence of other clearly defined causes.
• Chronic obstructive pulmonary disease: Persons with chronic obstructive pulmonary disease, including emphysema and chronic bronchitis, may have exacerbations during and after a URI.
• Lower respiratory tract disease and sepsis: These conditions represent serious complications, especially in patients with immunocompromise. Lower respiratory tract disease should be considered when symptoms such as fever, cough, sputum, and malaise worsen progressively or after initial transient improvement. Tachypnea and dyspnea are also signs of lower respiratory involvement.
• Bacterial superinfection: Viral infection and resulting inflammation may make an individual susceptible to concomitant or sequential infection with a bacterial agent. S pneumoniae, S aureus, H influenzae, and Streptococcus pyogenes are common superinfecting agents. Meningococcal disease may cause superinfection with influenzal infections.
• Airway complications: Inflammation of the larynx and trachea area may lead to airway compromise, especially in children and in patients with narrowed airways due to congenital or acquired subglottic stenosis. The work of breathing during epiglottitis or laryngotracheitis may lead to respiratory failure. Sleep apnea may occur from hypertrophied tonsils.
• Deep tissue infection: This may occur by extension of the infection into the orbit, middle ear, cranium, or other areas. Peritonsillar abscess (quinsy) may complicate bacterial pharyngitis, leading to difficult swallowing and pain radiating to the ear. Retropharyngeal abscess may also complicate pharyngitis. Lemierre syndrome is an extension of pharyngitis that leads to a suppurative thrombophlebitis of the internal jugular vein; septic thromboemboli may then spread throughout the body. Complications of sinusitis include orbital cellulitis, subperiosteal abscess, orbital abscess, mastoiditis, frontal or maxillary osteomyelitis, subdural abscess, cavernous sinus thrombosis, and brain abscess. Suspect a deep tissue infection when a patient has orbital swelling, proptosis, impaired extraocular movements, or impaired vision. Signs of increased intracranial pressure (eg, papilledema, altered mental status, neurologic findings) may suggest intracranial involvement.
• Encephalitis, meningitis, or subarachnoid hemorrhage: These may follow a URI.
• Local extension: Osteomyelitis may complicate persistent or recurrent sinusitis. Osteomyelitis may affect the orbital plate, frontal bone, or sphenoid bone. Mucoceles are expanding cystic defects of the paranasal sinuses that may result from prolonged sinusitis. Epiglottic abscess may result from epiglottitis.
• Lymphadenitis: It may follow URI.
• Guillain-Barré syndrome: This syndrome may manifest as an ascending polyneuropathy a few days or weeks after a URI.
• Reye syndrome: In children or adolescents,  the use of aspirin during a viral infection may cause Reye syndrome. Aspirin is contraindicated for the management of fevers in children or adolescents.
• Cardiovascular disease decompensation: URI, especially with fever, may increase the work of the heart, adding strain to persons with suboptimal cardiovascular status.
• Myositis or pericarditis: These may result from viral infection.
• Hyperglycemia: It may occur during infection in patients with diabetes.
• Cough complications: Rib fracture may be seen following an episode of severe coughing. Hernia may develop following an episode of severe coughing.

Complications of specific conditions

• Complications of group A streptococcal disease: Group A streptococcal pharyngitis is special concern because its complications include streptococcal toxic shock syndrome, ARF, acute glomerulonephritis, and scarlet fever.  
  • ARF affects approximately 3% of patients with strep throat, primarily persons aged 6-20 years. The condition develops approximately 20 days after streptococcal pharyngitis occurs, and it may last several months. Signs of rheumatic fever include arthritis and valvular disease. Uncommon features include an expanding truncal exanthem, subcutaneous nodules, and chorea.
  • Poststreptococcal glomerulonephritis can affect persons of any age group, but it is most common in children aged 3-7 years. Boys are affected slightly more often than girls. Patients with glomerulonephritis may have loss of appetite, lethargy, dull back pain, and dark urine. Blood pressure may be elevated, and edema may occur.
  • Scarlet fever is a self-limited exanthem that spreads from the chest and abdomen to the entire body. Tiny red papules create a rough skin texture similar to that of sandpaper. The rash is typically blanching. Although it typically affects the face, circumoral pallor is present. During recovery, the skin on the fingers and toes peels.
• Complications of EBV mononucleosis: Complications can include splenic rupture, hepatitis, Guillain-Barré syndrome, encephalitis, hemolytic anemia, agranulocytosis, myocarditis, Burkitt lymphoma, nasopharyngeal carcinoma, and a rash with concomitant use of ampicillin.
• Complications of diphtheria: Complications may include airway obstruction, myocarditis, polyneuritis, thrombocytopenia, and proteinuria. Among patients who survive diphtheria, as many as 20% have permanent hearing loss or other long-term sequelae.¹¹
• Complications from pertussis:  From 2001-2003, 33 cases of encephalopathy and 56 cases of pertussis-related deaths were reported. Fifty-one (91%) of the pertussis-related deaths were among infants younger than 6 months, and 42 (75%) of the deaths were among infants younger than 2 months.¹³
• Complications of influenza: These include bacterial superinfection, pneumonia, volume depletion, myositis, pericarditis, rhabdomyolysis, encephalitis, meningitis, myelitis, renal failure, and disseminated intravascular coagulation. As with any systemic infection, the flu poses a risk of worsening underlying medical conditions, such as heart failure, asthma, or diabetes. After influenzal infection, children may experience sinus problems or otitis media.

Prognosis

• Nasopharyngitis
  • A common cold may last up to 14 days, with symptoms averaging 7-11 days in duration.³
  • Fever, sneezing, and sore throat typically resolve early, whereas cough and nasal discharge are among the symptoms that last longest.
  • Attendance at daycare may affect the duration of symptoms in young children. In one study, the duration of viral URI ranged from 6.6 days for 1- to 2-year-old children in home care to 8.9 days for children younger than 1 year who were in daycare. Young children in daycare were more likely to have protracted respiratory symptoms lasting more than 15 days.⁵³
  • Most patients with influenza recover within a week, although cough, fatigue, and malaise may persist for up to 2 weeks. For newborns, elderly persons, and patients with chronic medical conditions, the flu may be life threatening. More than 200,000 people are hospitalized because of complications of the flu, with 0.36 deaths occurring per 100,000 patients each year.¹⁸
• Pharyngitis
  • Viral pharyngitis typically resolves in 1-2 weeks.
  • In patients with penicillin-sensitive streptococcal pharyngitis, symptomatic improvement is expected within 24-72 hours after the start of treatment. The clinician should be aware of potential complications. Treatment failures are common and mainly attributed to poor adherence, antibiotic resistance, and untreated close contacts. A chronic carrier state may develop with group A streptococcal infection. Eradicating the pathogen is difficult in these cases; however, carriers without active symptoms are unlikely to spread group A streptococci, and they are at low risk for developing rheumatic fever. The risk of mortality is significant in patients who progress to streptococcal toxic shock syndrome, which is characterized by multiorgan failure and hypotension.
  • With infectious mononucleosis from EBV, complete resolution of symptoms may take up to 2 months. Acute symptoms rarely last more than 4 months. EBV typically remains dormant throughout the patient's life. Reactivation of the virus is not usually symptomatic.
• Rhinosinusitis: The prognosis is generally favorable for acute rhinosinusitis, and many cases appear to resolve even without antibiotic therapy. As many as 70% of immunocompetent adults with rhinosinusitis begin to improve within 2 weeks of presentation without antibiotics. With antibiotics, up to 85% have improvement at 2 weeks. Complete resolution may take weeks to months.
• Epiglottitis: The prognosis is favorable with appropriate airway management, and most patients noticeably improve within 24-48 hours after antibiotics are started. Rarely, cases of epiglottitis may recur. Recurrent symptoms raise concern about potential underlying disorders, such as rheumatic conditions, sarcoidosis, or occult malignancy.
• Laryngitis and laryngotracheitis: Recovery is usually complete. With croup, laryngotracheobronchitis typically begins to improve within 3-4 days. However, patients may have a recurrence, including during the same season. Recovery from whooping cough is typically complete. However, paroxysms of coughing may last for several weeks. Infants and young children are most susceptible to severe courses that include respiratory compromise. Deaths from pertussis have been rare since the advent of the pertussis vaccine.

Patient Education

Address the patient's expectations about antibiotic therapy. Validate the patient's symptoms and their severity, listen to the concerns expressed, and educate about possible consequences of inappropriate antibiotic use, including consequences affecting the patient and the community.

Many people hold misperceptions about the duration and intensity of symptoms associated with URI and about the benefits and risks of antibiotic therapy. Some are unaware that cold symptoms may last as long as 14 days. Some believe that antibiotics will help them avoid serious disease and recover more quickly than without treatment. Patients may expect to receive antibiotics solely based on the severity of their symptoms, and they may not appreciate the negative consequences of using antibiotics in viral disease.

Actively promote self-care, and outline a realistic time course for the resolution of symptoms. Reassure the patient about access to clinical care and follow-up in the event that symptoms progress. Briefly explore factors that may have contributed to the current infection, and address prevention for the future.

Patient satisfaction is less linked to antibiotic prescriptions and more linked to the quality of the physician-patient interaction. Reflecting understanding of the details of the patient's situation, expressing concern for the patient's well-being, explaining how recommendations are appropriately tailored to the individual's current condition, and providing reassurance are important to patient satisfaction.

Patients should be counseled on handwashing and proper methods for covering coughs and sneezes. Additionally, smoking cessation encouragement and materials should be provided. When antibiotics are prescribed, patients should be instructed to complete the full course of antibiotic therapy.

Patients should be instructed to follow up when indicated or if symptoms worsen. Finally, patients with infectious mononucleosis should be instructed to avoid contact sports for 6 weeks because of the possibility of splenic rupture.  

For patient education resources, visit eMedicine's Headache Center Also, see eMedicine's patient education articles on Sinus Infection and Sore Throat.

Miscellaneous

Medicolegal Pitfalls

• A high index of suspicion is required for patients presenting with symptoms and signs consistent with epiglottitis. Such patients require immediate transfer to the nearest hospital for airway management.
• Do not perform unnecessary medical procedures that might result in agitation and respiratory collapse, especially in patients with epiglottitis or laryngotracheobronchitis.
• Mass lesions, such as retropharyngeal or peritonsillar abscess, or intraorbital abscesses, require immediate surgical evaluation.
• Diagnose and treat group A streptococcal pharyngitis to reduce the risk of ARF.
• Avoid unnecessary radiation exposure from imaging studies, especially in pregnant women and young children.
• Be alert for signs of immunosuppression because progression to lower respiratory tract and systemic disease is common.
• Avoid the use of aspirin during viral infection in children to avoid Reye syndrome.
• In pregnant or lactating women, choose medications in light of their effects on the fetus or baby.
• Carefully document follow-up instructions, signs and symptoms of recurrence, and complications.

• Search for CME/CE on This Topic »

• Cellulitis, Preseptal (Ophthalmology)
• Rhinoviruses (Infectious Diseases)
• Influenza (Infectious Diseases)
• Streptococcal Infection, Group A (Pediatrics: General Medicine)

• Headache Center
• Sinus Infection Symptoms
• Sinus Infection Overview
• Sinus Infection Causes
• Sinus Infection Treatment
• Sore Throat Overview
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