Upper Respiratory Tract Infection Treatment & Management

Most upper respiratory tract infections (URIs) are self-diagnosed and self-treated at home. Patients who present with URIs often benefit from reassurance, education, and instructions for symptomatic home treatment.

Symptom-based therapy represents the mainstay of URI treatment in immunocompetent adults, although antimicrobial or antiviral therapy is appropriate in selected patients (see Medication). Several URIs warranting special attention are described in this section.

In November 2013, The American Academy of Pediatrics released a set of three basic principles for the effective use of antibiotics to treat pediatric URIs, including acute otitis media, acute bacterial sinusitis, and streptococcal pharyngitis. ^{[40, 41]} The principles are as follows:

• Accurate diagnosis of a bacterial infection;

• Consideration of the risks vs benefits of antibiotic treatment; and

• Implementation of judicious prescribing strategies, including selection of the most effective antibiotic, prescription of an appropriate dose, and treating for the shortest possible duration.

These principles will help healthcare providers distinguish bacterial infections from viral infections.

Little et al evaluated the effectiveness of delayed antibiotic prescribing strategies for respiratory tract infections in 889 United Kingdom primary care patients (age ≥3 y) assessed as not requiring immediate antibiotics. They reported that using strategies of either no or delayed prescription resulted in fewer than 40% of the patients across 25 practices using antibiotics. ^[42]  Delayed prescribing strategies consisted of recontact for a prescription, postdated prescription, collection of the prescription, and giving the prescription (patient led).

Moreover, no or delayed prescription strategies were associated with patients having less strong beliefs in the use of antibiotics, and symptomatic outcomes were similar to those observed in patients who received immediate prescription. ^[42]

The risk for airway compromise is notable, especially in children. Immediately admit the patient to the nearest hospital. Adults with epiglottitis typically have a relatively gradual course. However, some older children and adults may have respiratory compromise, especially those with congenital or acquired subglottic stenosis.

The treatment of epiglottitis in adults requires individual tailoring of therapy on the basis of the severity of the disease at presentation and the course of the disease as it unfolds under observation. An anesthesiologist or otorhinolaryngologist should be involved early on.

Avoid instrumentation in suspected epiglottitis. Limit the examination to observation and an assessment of the vital signs. Insertion of tongue depressors or other instruments may provoke airway spasm and precipitate respiratory compromise. Keep the patient comfortable, and avoid unnecessary examinations.

Patients must be monitored for respiratory fatigue, visually and with continuous pulse oximetry. Because immediate intubation is required in the event of respiratory failure, the availability of equipment and qualified personnel is critical. If endotracheal intubation is not possible, cricothyroidotomy may be required.

Oxygen is administered according to pulse oximetry results. Dry air may worsen inflammation, so the use of humidified oxygen or a room humidifier is recommended.

Medications

Presumptive intravenous antibiotics are indicated, tailored to results from blood cultures. Empiric coverage for Haemophilus influenzae is appropriate. Antibiotic therapy should begin after blood cultures (and epiglottic cultures, if laryngoscopy is performed) are taken. Common choices include ceftriaxone or other third-generation cephalosporins, cefuroxime, and cefamandole. After culture and sensitivity results are available, therapy may be further tailored. Close contacts should receive prophylactic oral therapy.

Either intravenous or inhaled glucocorticoids are sometimes given to reduce inflammation. However, controlled trials of the effectiveness of this approach in epiglottitis are limited. Correct volume deficits with intravenous fluids. Avoid sedatives that may suppress the respiratory drive.

Aerosolized racemic epinephrine is sometimes used to reduce mucosal edema in patients with croup, but its value in epiglottitis is not defined, and adverse events have been reported in patients with this disorder. ^[43] Beta₂ -agonists are not typically used in patients who do not have asthma.

Hospitalization may be necessary in patients with laryngotracheitis, especially in infants and young children who have hypoxemia, volume depletion, a risk for airway compromise, or respiratory fatigue. Mild cases of croup (ie, laryngotracheobronchitis) may be managed at home with moist air inhalation. Patients with diphtheria may require isolation and hospitalization for airway management.

Hospitalized patients require monitoring for respiratory fatigue, visually and with continuous pulse oximetry. Clinicians with the expertise to perform immediate intubation and access to the necessary equipment are required if respiratory failure is a possibility. If endotracheal intubation is not possible, cricothyroidotomy is indicated for respiratory failure. Keep the patient comfortable, and avoid unnecessary procedures and examinations.

Administer humidified oxygen to all hypoxemic patients. In patients who do not require oxygen therapy, a cool-mist humidifier may be used, as dry air may worsen inflammation. Heliox, a mixture of helium and oxygen, compared favorably with inhaled racemic epinephrine in a small study of pediatric patients with moderate to severe croup. ^[44]

Medication

Intravenous or oral glucocorticoids are commonly used to reduce symptoms and shorten hospitalization in patients with moderate to severe croup. Inhaled steroids may be considered in cases that are not severe; however, evidence from large, controlled trials regarding the use of inhaled steroids in croup is lacking.

Inhaled racemic epinephrine may temporarily dilate the airways by relaxing bronchial smooth muscle and causing vasoconstriction that may reduce mucosal inflammation. Epinephrine may be considered in patients with persistent stridor. Because rebound edema may occur when inhaled epinephrine is stopped, monitoring and observation is required for several hours afterward.

In patients with croup, the use of steroids may reduce the need for epinephrine. In patients with whooping cough, evidence is insufficient to justify the use of long-acting beta agonists, antihistamines, or pertussis immunoglobulin. ^[45] Antibiotics are appropriate for whooping cough (pertussis); however, croup is typically a viral condition. Blood cultures should be ordered.

Correct volume deficits with intravenous fluids. Avoid sedatives that may suppress the patient's respiratory drive.

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. ^[6] Data from controlled trials indicated that more than half of adults and children improved within 3-10 days of treatment with placebo; however, the data also showed that at both time points, the use of amoxicillin increased the percentage of patients who improved.

The 2012 Infectious Disease Society of America (IDSA) guidelines on sinusitis recommend considering treatment if symptoms persist without improvement for 10 days or longer or if symptoms are severe or worsen during a period of 3-4 days or longer. ^[7] The 2013 American Academy of Pediatrics (AAP) guidelines recommend antibiotic treatment for children with severe onset or a worsening course; however, in children with persistent illness, clinicians should either treat the patient or observe him/her for an additional 3 days. ^[3]

Antibiotic therapy

First-line antibiotics for 5-7 days are appropriate in most adults; 2012 IDSA guidelines recommend 10-14 days of treatment in children. Patients at risk for antimicrobial resistance include the following:

• Those younger than 2 years or older than 65 years

• Children in day care

• Patients who took antibiotics in the previous month

• Patients who were hospitalized within the previous 5 days

• Patients with comorbidities

• Patients who are immunocompromised

For such patients, second-line antibiotics for 7-10 days is recommended. If symptoms do not improve in 3-5 days, broadening coverage to another antibiotic class may be considered.

Treatment should begin with an agent that most narrowly covers likely pathogens, including Streptococcus pneumoniae, nontypeable H influenzae, and Moraxella catarrhalis. Initial first-line options include amoxicillin/clavulanate. ^[7] High-dose therapy (2 g orally twice daily or 90 mg/kg/day orally twice daily) may be considered in geographic regions where invasive penicillin sensitivity is 10% or greater, as well as in patients with any of the following:

• Severe symptoms such as high fever and threat of suppurative complications

• Day-care attendance

• Age under 2 or over 65 years

• Recent hospitalization

• Antibiotic use in the past month

• Immunocompromise

Per IDSA guidelines, in penicillin-allergic patients, doxycycline is an alternative, as are respiratory fluoroquinolones such as levofloxacin or moxifloxacin. Macrolides, trimethoprim-sulfamethoxazole, and second- or third-generation cephalosporins are not recommended for empirical therapy, due to high rates of S pneumoniae resistance.

In patients who worsen or do not improve after 3-5 days of empiric therapy, guidelines recommend exploration for resistant pathogens, structural abnormality, or noninfectious etiology. In such patients, cultures should be obtained by direct sinus puncture or middle meatus endoscopy rather than with nasopharyngeal swabs. ^[7]

Adjunctive therapy for adults includes nasal saline irrigation. Intranasal steroids may be considered, especially for those with a previous history of allergic rhinitis. Neither oral nor nasal antihistamines or decongestants are recommended for acute bacterial sinusitis. ^[7]

Beginning treatment of group A streptococcal disease before positive results are confirmed is not ideal, because therapy is often inadvertently continued even if the results are negative. Chronic carriage of group A streptococcus does not warrant antibiotic treatment.

Oral penicillin or amoxicillin 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 treating pharyngitis and for preventing acute rheumatic fever. ^[2] If compliance with oral therapy is a concern, consider a single intramuscular injection of benzathine penicillin G.

A first-generation cephalosporin may be used in patients with non-anaphylactic penicillin allergy. Options for penicillin-allergic patients include clindamycin or clarithromycin for 10 days or azithromycin for 5 days. ^[2] For patients with recurrent or complicated group A streptococcal infections, cephalosporins may be appropriate.

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 whether 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.

Patients who experience repeated bouts of acute pharyngitis with laboratory evidence of group A streptococcal infection may be experiencing actual streptococcal pharyngitis episodes. However, such patients may potentially be chronic pharyngeal streptococcal carriers who are experiencing repeated viral infections.

The 2012 IDSA guidelines suggest that efforts to identify group A Streptococcus carriers are not ordinarily justified, nor do carriers generally require antimicrobial therapy. Group A Streptococcus carriers are unlikely to spread streptococcal pharyngitis to close contacts, and they are at little or no risk for developing suppurative or nonsuppurative complications themselves. ^[2]

Adjunctive therapy for strep pharyngitis includes pain relievers; aspirin should be avoided in children due to risk of Reye syndrome. Corticosteroids are not recommended. ^[2]

Specific therapies are available for gonococcal and herpes simplex virus (HSV) pharyngitis. Gonococcal pharyngitis may be difficult to eradicate. Gonococcal therapy is typically a single intramuscular dose of ceftriaxone. Although coincident Chlamydia trachomatis pharyngitis is rare, Chlamydia coinfection in gonococcal urethritis, cervicitis, or proctitis sometimes occurs, so treatment for gonococcus and chlamydia are often combined. ^[32] HSV pharyngitis may be treated with antivirals. See Herpes Simplex for additional details.

Pertussis (whooping cough) infection warrants treatment with a macrolide antibiotic. Close contacts should receive prophylactic treatment.

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 the availability and use of this antitoxin.

For treatment options in seasonal influenza, see Influenza. The CDC tests circulating influenza viruses for resistance patterns to antiviral medications and issues treatment guideline updates each influenza season. ^[46]

Special attention is warranted in patients with suboptimal immune defenses, for reasons including the following:

• Lack of a spleen: Lowers resistance to infection with encapsulated bacteria

• HIV infection

• Cancer or cancer therapy

• Dialysis

• Stem cell or organ transplantation

• Congenital immunodeficiency

Appropriate antimicrobial therapy and close follow-up may be appropriate, because a simple URI may quickly progress to a systemic illness in immunocompromised patients. Although the threshold for hospitalization is lowered for these patients, their risks of nosocomial infections must be weighed against the benefits of close monitoring in the inpatient setting.

Although antivirals do not generally play a role in most cases of upper respiratory tract disease, consider available treatment options for HSV pharyngitis, respiratory syncytial virus (RSV) infection, and cytomegalovirus (CMV) infection in immunocompromised patients.

HSV infection may be treated with acyclovir, famciclovir, or valacyclovir. For CMV 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.

Deep tissue infections of adjacent structures, such as a peritonsillar, oropharyngeal, intraorbital, or intracranial abscess, warrant hospitalization and immediate consultation with a surgeon. These infections may compromise the airway, vision, or neurologic function.

Repeated streptococcal infection may be an indication for surgical intervention. In patients with 4-5 confirmed group A streptococcal infections in a single year or in those with chronic sore throat with adenopathy that is not responsive to treatment over 6 months, tonsillectomy may be considered. For more information, see Tonsillectomy.

In a study from the Netherlands of children aged 1-6 years with recurrent URI, adenoidectomy did not reduce URI episodes compared with initial watchful waiting. ^[47] (Adenoidectomy rates in the Netherlands are several times that in the United States.)

Surgery is rarely warranted in acute rhinosinusitis but may be considered under the following circumstances:

• Sinusitis has not responded to months of medical therapy

• A mucopyocele is present

• A fungal sinus infection exists

• Infection extends to the bone

If possible, the sinus mucosa should be left intact during sinus surgery. Functional endoscopic sinus surgery is designed to promote drainage of the sinuses by altering the ostiomeatal complex. For surgical management of chronic sinusitis, see Chronic Sinusitis.

The following home-care measures may help to provide relief of nasal and sinus symptoms:

• Warm, moist air

• Nasal saline

• Hydration

• Warm facial packs

• Bulb suction (for infants)

• Avoidance of nasal irritants (eg, cigarette smoke, indoor and outdoor air pollutants)

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, hot showers

• Use a vaporizer to increase humidity in rooms

If a vaporizer is used, the water must be changed daily to prevent microbial growth, especially with heated vaporizers. Heated systems may pose a risk for scalding injuries.

One way to provide moist, warm air is to pour boiled water into a shallow pan or bowl placed in a stable location (eg, middle of a kitchen counter) and have the patient drape a cloth over his/her 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 may provide temporary relief of congestion by removing nasal crusts and dried secretions. A systematic review of nasal saline irrigation as an adjunct in chronic rhinosinusitis symptom management concluded that the evidence shows symptom relief and that irrigation is well tolerated by most patients. ^[48] Patients with sinusitis experienced symptomatic benefit from use of a neti pot method of nasal irrigation. ^[49]

Saline drops or sprays are commercially available. A homemade normal saline solution can be prepared by placing a quarter 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.

Drinking 8 or more 8-oz glasses of water, juice, or noncaffeinated beverages daily may help to thin mucous 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 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.

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.

Home-care measures to relieve throat symptoms include warm saline gargles, which may reduce associated edema; lozenges; popsicles; and cold and slushy beverages. Avoid choking hazards in small children.

Home-care measures to relieve cough include reducing 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. ^[50]

Home-care measures to improve sleep include sleeping with the head and shoulders slightly elevated, which 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 naris. When the person is lying recumbent on one side, the naris 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.

Treatment of an uncomplicated URI is focused on specific measures to reduce symptoms, including use of the following:

• Oral or topical decongestants

• Ipratropium bromide

• Antihistamines

• Topical and systemic steroids

• Saline nasal drops

• Guaifenesin

• Topical phenol or lidocaine

• Cromolyn

Oral and topical decongestants

Oral decongestants may provide symptom relief for patients 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 of oral decongestants include the following:

• Anxiousness

• Insomnia

• Tachycardia and dysrhythmias

• Elevated blood pressure

• Palpitations

• Tremor

• Urinary retention

Exercise caution in patients with heart disease, hypertension, prostate enlargement, glaucoma, anxiety, hyperthyroidism, or other medical conditions and in 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 of over-the-counter preparations. ^[51] Numerous over-the-counter cough and cold preparations are labeled "do not use" in children younger than 4 years. ^[52]

Topical decongestants such as phenylephrine and oxymetazoline may provide rapid temporary relief of nasal obstruction. However, rebound congestion may occur after cessation of use. To avoid this rebound congestion, limit topical agents to 3-4 days of use. In addition, these decongestants may cause throat irritation in some individuals.

One study, in which oxymetazoline was administered to patients with a nasal bellows, suggested that oxymetazoline did not accelerate the rate of healing of acute maxillary sinusitis, as judged by sinus radiographs and subjective symptom scores. The researchers concluded that decongestion of the sinus ostia may not be of primary importance in the healing of acute sinusitis. ^[53]

Ipratropium bromide

This agent, which is an anticholinergic, 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 mucus and nasal dryness were higher in the treated group than in the control group. ^[54]

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. (Such effects have been reported for clemastine fumarate in patients with the common cold.) ^[55]

These older antihistamines, however, are sedating. In nonallergic children with acute bacterial rhinosinusitis, data regarding the efficacy of H1 blockers as adjuvants to antibiotics are insufficient. ^[56] In theory, antihistamines may thicken secretions and thus reduce sinus drainage.

Steroids

Topical and systemic steroids 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. ^[56] However, for adults with recurrent acute rhinosinusitis or acute rhinosinusitis superimposed on chronic rhinosinusitis, adjunctive use of high-dose nasal corticosteroids may decrease symptom duration and improve clinical success rates. ^{[1, 57]}

Saline nasal drops

Saline nasal 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. ^[48]

Guaifenesin

The use of guaifenesin, a mucolytic, is commonly suggested with the intention of thinning secretions. However, data regarding its effectiveness in reducing secretions and promoting drainage in persons with nasopharyngitis or rhinosinusitis are limited.

Topical phenol and lidocaine

Lozenges, gargles, or sprays that contain phenol may provide temporary relief of sore throat. In young children, however, 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

Intranasal cromolyn sodium is typically used for relief of allergic rhinitis. Data are insufficient, however, to permit evidence-based recommendations regarding its use 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. ^[45] As stated earlier, 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 of over-the-counter preparations in young children. ^[51] Since 2008, many nonprescription cough and cold product labels state "do not use" in children younger than 4 years. ^[52]

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, may be useful in postinfectious cough (3-8 wk after the onset of the URI) in adults. Inhaled steroids may be considered in postinfectious cough (3-8 wk after URI onset) if ipratropium fails to control it. 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.

Several agents (eg, codeine, guaifenesin, dextromethorphan) are intended for the symptomatic relief of cough. However, evidence is mixed regarding effectiveness of these agents. While codeine may inhibit cough under various circumstances, data are limited regarding its effectiveness in reducing acute cough from URI. 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.

Dextromethorphan, a centrally acting cough suppressant, may be considered for the treatment of postinfectious cough in adults if other medications fail. However, this agent may have limited efficacy in treating cough related to acute URI. One study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI. ^[50]

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. ^[58]

Codeine is an effective, centrally acting cough suppressant in adults. As with other centrally acting antitussives, additional evidence is required to create evidence-based recommendations for the use of codeine in URI-related cough in children. ^[58] 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.

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 asthma or chronic obstructive pulmonary disease exacerbated by URI.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to reduce discomfort due to cough. Avoid aspirin in children with viral illness because aspirin is associated with Reye syndrome.

Inhaled cromolyn sodium is used for control of chronic asthma. 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

Fever may be physiologically helpful in eliminating pathogens from the body. In some individuals, however, fever poses a risk of provoking underlying illness. In a fragile cardiac patient, for example, 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 the relief of fever, sore throat, myalgias, facial pain, and other uncomfortable sensations in pediatric patients because aspirin is associated with Reye syndrome. Avoid the use of respiratory depressants in patients with serious airway congestion or compromise.

Steroids should not be routinely used for pharyngitis pain relief. An analysis of steroids added to usual care for pharyngitis potentially caused by group A streptococcus noted a 4.5-hour reduction in time to pain relief and improved pain relief at 24 hours with oral or injected steroids. ^[59] However, significant heterogeneity was reported in the pooled results.

Complementary and alternative therapies

Alternative therapies and traditional folk remedies are widely used to treat URIs. While some may 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. ^[60] However, the US Food and Drug Administration (FDA) has issued a public health advisory against the use of intranasal zinc because of reports of long-lasting or permanent loss of smell associated with its use. In some cases, anosmia occurred with the first dose; in others, it occurred after multiple uses of intranasal zinc. ^[61]

Oral zinc has been studied as a supplement to prevent colds and as an acute remedy. A meta-analysis of randomized trials of oral zinc (lozenges, syrup, tablets) concluded that, statistically, healthy people who took oral zinc supplements for 5 months or more experienced fewer colds. ^[62]

The study also found that when oral zinc was taken as an acute remedy within 24 hours of symptom onset, it statistically improved symptom duration and severity. However, firm recommendations regarding routine use in healthy individuals are difficult to make, due to variability inherent in the course of URIs; the variability in dosing, timing, and formulations studied; and the balance required against side effects such as nausea.

Echinacea

Echinacea preparations are widely used for common colds. A meta-analysis noted that echinacea preparations tested in clinical trials differ greatly, but found some evidence that Echinacea purpura preparations may be effective in the early treatment of colds in adults. ^[63] In a randomized study of common cold symptom severity in older children and adults, standardized echinacea tablets started within the first 24 hours of symptoms were not superior to placebo. ^[64]

Vitamin C

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

Traditional folk remedies

Folk remedies include sipping hot water with a teaspoon of honey and fresh lime or lemon juice. However, the acids in fresh citrus may be irritating to sore throat. Honey has more demulcent qualities.

One study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI. ^[50] Honey should not be given to infants, because of the rare possibility that it may contain Clostridium botulinum spores, which may germinate in the intestine and produce toxin that causes infant botulism.

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). A study of 60 adults revealed a temporary favorable trend toward improvement of pharyngitis symptoms when the patients drank a tea containing these herbs, compared with placebo. ^[65] Prolonged, excessive use of licorice may affect potassium levels and volume status.

Increased fluids are warranted to replace insensible losses and reduced oral intake. However, alcohol may cause swelling of the nasal and paranasal sinus mucosae.

Antibiotics alter the gastrointestinal flora, and some foods may not be as digestible for days or weeks after antibiotics are used. Consumption of yogurt containing active cultures has been advocated as an aid to restoring normal flora after antibiotic therapy. A meta-analysis suggests that probiotics may prevent antibiotic-associated diarrhea; Saccharomyces boulardii and lactobacilli may be particularly useful in this situation. ^[66]

Patients with the common cold may consider returning to their usual physical activity, including aerobic activity, if their symptoms are limited to the nose and throat. However, if cough, fever, or other systemic symptoms are present, rest is indicated to aid in recovery from the URI.

Patients with infectious mononucleosis should be instructed to avoid contact sports for 6 weeks because of the possibility of splenic rupture. Voice rest is indicated for patients with laryngitis or laryngotracheitis.

Patients may experience increased discomfort from upper airway infection during air travel. As atmospheric pressure drops during takeoff, expansion of soft tissues may block the eustachian tubes and increase pressure sensations in the sinuses.

Chlorine from pools may be irritating to inflamed nasal membranes. Diving, especially at depth, may cause uncomfortable pressure and impair drainage of the paranasal sinuses.

Several measures can reduce susceptibility to URIs. In newborns, the practice of breastfeeding transfers protective antibodies through the mother's milk, providing passive immunization against numerous pathogens.

In older children, adolescents, and adults, an adequate diet is necessary 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 these from food may have more nutritional benefit than taking individual supplements.

Lifestyle measures such as smoking cessation and reduction of exposure to secondhand smoke may reduce the incidence of URIs. Regular, moderate exercise may reduce susceptibility to URIs, whereas intensive training in high-performance endurance athletes may increase susceptibility. ^[67]

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

Hygiene

Handwashing 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. Discourage sharing of items passed from hand to 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.

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.

Avoidance and treatment of the patient’s contacts

People 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 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.

Patients with group A strep confirmed with culture or rapid antigen testing should not attend day care, 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. ^[2] 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. ^[1]

Patients who are ill with influenza or similar infections should remain at home (except for receiving medical care and other necessities) until at least 24 hours have passed without a fever, without the use of fever-reducing medication.

To prevent the spread of epiglottitis, consider rifampin prophylaxis for close contacts of a patient with epiglottitis, especially when unvaccinated young children are among the contacts.

To prevent the spread of pertussis, patients should be isolated for 5 days. 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. ^[68]

To prevent the spread of diphtheria, isolation is warranted until 48 hours after antibiotics are started, after which diphtheria is not usually contagious. Household or other close contacts should receive benzathine penicillin or a 7- to 10-day course of oral erythromycin and an age-appropriate diphtheria booster. ^[68]

Orogenitally transmitted infections (eg, HSV infection, 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. ^[69] Patients with HSV pharyngitis should be counseled about the spread of infection, and their contacts should be evaluated.

Immunization and immunoprophylaxis

Vaccination against Haemophilus influenzae type b has dramatically reduced rates of epiglottitis. 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). ^[70] Updated CDC recommendations are available, including guidance for children, pregnant patients, and adults (including those who may come into contact with young children). ^[71]

RSV passive immunoprophylaxis 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.

For information on influenza vaccination, see the Medscape Reference article Influenza, as well as the CDC Web page What You Should Know for the 2013-2014 Influenza Season. Chemoprevention is available for influenza; however, it does not replace vaccination.

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.

Airway obstruction from epiglottitis, tonsillar hypertrophy, peritonsillar abscess, retropharyngeal abscess, or other causes of an obstructive mass requires emergency consultation with a surgeon. Sleep apnea associated with tonsillar hypertrophy may also prompt surgical consultation. Neurologic findings or mental status changes in the setting of suspected intracranial suppurative complications warrant emergency consultation with a neurosurgeon.

Consider consulting an infectious disease specialist when patients have any of the following:

• HIV infection

• Cancer-related or congenital immunodeficiency

• Other immunocompromise

Patients with a chronic cough after a URI may benefit from a consultation with a pulmonologist or otorhinolaryngologist to evaluate persistent infection, asthma, gastroesophageal reflux disease, or other causes of chronic cough. Patients who have had 4-5 confirmed group A streptococcal infections in a single year or those with a chronic sore throat and adenopathy unresponsive to treatment over 6 months should be examined by an infectious disease specialist and/or surgeon.

Persistent hoarseness after 2 weeks warrants consultation with an otorhinolaryngologist. Patients with complex, persistent cases of rhinosinusitis should also be referred to an otorhinolaryngologist, for consideration of sinus puncture and aspiration.

In general, patients with URI should follow up with a physician if their symptoms do not improve, worsen within 72 hours, or recur. Patients with infectious mononucleosis should be instructed to follow up with their physician after a week. In patients with diphtheria, elimination of the organism should be documented with 2 consecutive negative culture results after the completion of therapy. ^[28]

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. ^[1]