key: cord-0770437-e25o1oio authors: Grief, Samuel N. title: Upper Respiratory Infections date: 2013-07-12 journal: Prim Care DOI: 10.1016/j.pop.2013.06.004 sha: 178cf12d3ee7a34be1246f01aab17261ace90ecd doc_id: 770437 cord_uid: e25o1oio Upper respiratory infections (URIs) are infections of the mouth, nose, throat, larynx (voice box), and trachea (windpipe). This article outlines the epidemiology, etiology, diagnosis, and management of URIs, including nasopharyngitis (common cold), sinusitis, pharyngitis, laryngitis, and laryngotracheitis. The common cold is a frequent cause of URIs and can be defined as inflammation of the nasal passages owing to a respiratory virus. The vast majority of these infections are self-limited and resolve without treatment. Frequency of the common cold varies per age group ( Table 1) . Although URIs can happen at any time, they are most common in the fall and winter months, from September until March, because these are the usual school months when children and adolescents spend a lot of time in groups and indoors. Furthermore, many URI viruses thrive in the low humidity of the winter. Signs and symptoms of the common cold are listed in Table 2 . Causes of the common cold are predictably viral, with the majority of these viruses falling into 1 of 200 virus strains from 6 main families; rhinovirus, influenza A/B/C, parainfluenza, respiratory syncytial virus, coronavirus, and adenovirus. Determining which virus is the causal agent is unnecessary in the overwhelming number of cases because symptomatic therapy and "tincture of time" usually result in a full resolution of the infection. The diagnosis of a common cold is almost always based on clinical findings. Distinguishing a common cold from a more potent viral illness, such as the influenza virus, is a matter of knowing the common symptoms and signs of the flu and comparing them with those of the common cold. In rare cases, virus is cultured from nasal washings, or identified by enzyme-linked immunosorbent assay or radioimmunoassay methods ( Table 3) . Hand washing is the single most important activity that can reduce the risk of URI. Numerous studies have confirmed that washing with soap or using hand sanitizer lowers the risk of transmission of URI and respiratory infections. 1, 2 Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on the hands of hospital and health care personnel. Antiseptic soaps and detergents are the next most effective, and nonantimicrobial soaps the least effective. 3, 4 Treatment of the Common Cold: Rest, fluids, and symptomatic measures Reassurance that the usual course is 6 to 10 days Humidification of inspired air Saline nasal rinse or Neti pot Topical decongestants: reduce edema and swelling of the nasal mucosa, promote drainage; fewer side effects than oral agents (phenylephrine: Afrin, Neosynephrine) Topical anticholinergics: control rhinorrhea but do not relieve congestion or sneezing (Atrovent nasal spray) Acute (rhino)sinusitis (AS) is defined as inflammation of the nasal mucosa and sinuses. 8 AS is very common. According to a recent national health survey, approximately 1 of 7 adults are affected 9 and diagnosed per year. 10, 11 Diagnosis Distinguishing between the common cold and AS is often a matter of symptom duration. Typical common colds are self-limited and last 7 to 10 days, whereas AS can last for up to 4 weeks. Symptoms of AS are similar to those of the common cold and include nasal congestion and discharge, facial pain over the sinuses, decreased sense of smell, and cough. 8 The waxing and waning phenomenon of symptoms sets AS apart from the common cold, usually with a mild improvement of symptoms after 5 to 7 days, followed by a worsening of symptoms, including new-onset fever, headache, and/or increased nasal discharge. 12 A bacterial origin is generally suspected and diagnosed if the following symptoms or signs are present: Purulent nasal discharge Maxillary tooth or facial pain Grief Unilateral maxillary sinus tenderness Worsening symptoms after initial improvement 12, 13 Diagnosis of acute bacterial sinusitis (ABS) can be made if there are 2 major or 1 major and 2 minor markers, and symptoms persist beyond 7 to 10 days, start out severe, and last at least 3 to 4 consecutive days or worsen after 5 to 7 days ( Table 4) . 12 According to the Institute for Clinical Systems Improvement (ICSI), plain sinus radiographs and other radiographic images are usually not necessary for diagnosis of sinusitis, and provide poor sensitivity and specificity. 14 Nasal endoscopy or antral puncture and culture of secretions are ideal tests, but are not feasible for the general practitioner and should be relegated to otolaryngologists, usually in the setting of diagnosing a chronic sinusitis. Discriminating between bacterial and viral AS is one of the most important determinants of treatment, Table 4 is helpful for diagnosing bacterial AS that would warrant antibiotic treatment. Bacterial causes of AS include: Selecting the appropriate antibiotic will help mitigate complications. Table 5 provides guidance. Duration of antibiotic therapy has been studied. A meta-analysis of 12 randomized controlled trials found no statistically significant difference between long-term and short-course antibiotics for cure or improvement of symptoms. 15 Five to 7 days of treatment with the appropriate antibiotic is considered effective for patients with uncomplicated ABS. Other treatments are listed in Table 6 , along with their usefulness. Additional comfort measures for treating AS include: Maintain adequate hydration (6-10 glasses of liquids per day) Apply warm facial packs (warm wash cloth, hot water bottle, or gel pack for 5-10 minutes 3 or more times a day to help with pain relief) Pharyngitis is one of the most common conditions encountered by the family physician. 18 The optimal approach for differentiating among various causes of pharyngitis requires a problem-focused history, a physical examination, and appropriate laboratory testing. Identifying the cause of pharyngitis, especially group A b-hemolytic streptococcus (GABHS), is important in preventing potential life-threatening complications. 18 Inflammation of the pharynx, caused by one of many different viruses and/or bacteria. Acute pharyngitis is one of the 20 most reported reasons for outpatient office visits Peak season is late winter and early spring Transmission of typical viral and Group A streptococcal (GAS) pharyngitis occurs mostly by hand contact and has an incubation period of 1 to 3 days (35% transmission) Pharyngitis is most likely caused by virus or bacteria 18, 19 Also caused by reflux, rhinitis and postnasal drip, persistent cough, and allergy NB. Consider testing for infectious mononucleosis if the patient is between 10 and 25 years old GAS pharyngitis accounts for 15% to 30% of infections in children and 5% to 15% in adults GAS is the most common cause of bacterial infection Physical signs of GAS include: Pharyngeal erythema and swelling Tonsillar exudates Edematous uvula Palatine petechiae Anterior cervical lymphadenopathy Determining how likely a pharyngitis is due to GAS infection has been studied. Criteria have been developed to assist the practitioner in making a clinical diagnosis ( Table 7) . Data from Refs. 10, 14, 16, 17 Upper Respiratory Infections Untreated, GAS pharyngitis lasts 7 to 10 days. These patients are infective during the acute phase of the illness and for 1 additional week, and are also at risk of suppurative complications (see later discussion) Effective antibiotic treatment decreases the infectious period to 24 hours, decreases symptoms, and prevents most complications The Infectious Diseases Society of America (IDSA) reiterates 2 principles of management: 1. Use of clinical and epidemiologic features to distinguish who may have GAS pharyngitis (see Table 7 ) 2. Antibacterial treatment of cases confirmed with a laboratory test (culture or rapid antigen testing) Antibiotic Therapy for GAS Pharyngitis GAS is universally sensitive to penicillin 20, 21 Drug of choice: penicillin V for 10 days 250 mg 3 times daily for pediatrics 500 mg 2 times daily for adults Benzathine G PCN injection for compliance problems Acute laryngotracheobronchitis (LTB) is an infectious-induced inflammatory condition affecting the larynx, trachea, and bronchi. Most common in children ages 6 months to 6 years, with the peak at 2 years 22 Hoarseness of voice followed by paroxysms of nonproductive, harsh, seal-like cough that ends with a characteristic inspiratory stridor. Fever, rhinorrhea, sore throat, and cough usually precede this. Symptoms may vary in intensity and last approximately 3 to 4 days if mild. Anterior-posterior radiograph view of the neck shows the subglottic obstruction. Etiology LTB is caused mostly by viruses, primarily parainfluenza virus types I and II, although others, such as influenza type A or B, respiratory syncytial virus (RSV), and adenovirus are also implicated. H influenzae type B is now a rare cause, thanks to routine immunization. Occasionally Mycoplasma pneumoniae can cause LTB. 22 Patients appear apprehensive and tend to lean forward The child may have tachypnea and might be using accessory respiratory muscles Inspiratory or expiratory stridor is prominent 23 Pulmonary examination may reveal rhonchi, crepitations, or wheezing Breath sounds may be diminished if upper airway obstruction is severe and air entry is greatly decreased Upper Respiratory Infections The white blood cell count may be normal or mildly elevated. Noninvasive pulse oximetry to monitor the oxygen saturation is recommended. 25 Arterial blood gas assessment shows hypoxemia and/or hypercapnia, depending on the severity of the disease. Microbiologic diagnosis can be established by serology, viral or bacterial cultures from the pharynx, or rapid antigen detection enzyme immunosorbent assays such as for RSV or influenza type A. Lateral neck radiographs show overdistended hypopharynx, subglottic narrowing that is wider on expiration than inspiration, thickened vocal cords, and a normal epiglottis. Anterior-posterior views of the neck show edematous subglottic walls converging to create a characteristic "steeple sign." 26 There may also be diffuse narrowing of the trachea and bronchi. Acute epiglottitis is a major differential diagnosis to be considered when a child presents with these symptoms. Radiographs of the neck can easily help differentiate the 2 conditions. Other causes of similar symptoms include foreign-body aspiration, which can be determined by history, radiographs, or endoscopic evaluation. Membranous croup or bacterial tracheitis should also be considered if the child presents with a clinical picture similar to croup but appears more toxic and has subglottic narrowing on radiographs of the neck. In milder cases, a simple URI is more likely. If sore throat is prominent, ensure adequate visualization of the tonsils to confirm absence of peritonsillar abscess. Allergic reactions (angioedema) and airway anomalies such as trachea/ laryngomalacia should also be entertained. 22,24 Severe croup, as may occur with influenza type A, may require tracheotomy or intubation in approximately 13% of patients and have an associated mortality of 0% to 2.7%. 15 A small percentage of children with prolonged intubation or severe disease may develop subglottic stenosis. A few follow-up studies have shown an increase in hyperactive airways in children with a history of croup. Outpatient management of croup in children is feasible, as noted in Fig. 1 . The cornerstone of medical management is nebulized epinephrine and dexamethasone. 24 Racemic or L-epinephrine may be used; its onset is 1 to 5 minutes and its effects last up to 2 hours. Dexamethasone in appropriate doses partners well with epinephrine, as its onset of action is 6 hours. 17 Nebulized budesonide is also now a therapeutic option. 27 Oxygen may be administered, along with humidification, to avoid agitation and maintain oxygen saturation higher than 92%. 28 Some children will fail medical management and require intubation. Intubation should be done in fully equipped units and preferably via the nasotracheal route. Extubation is usually attempted in about 5 to 7 days if extubation criteria are met. Extubation criteria include decreased secretions, decreased leakage around the endotracheal tube (which indicates decreased edema), and an alert child. Failure to extubate should prompt further endoscopic evaluation. 22 Croup is mostly a self-limited disease with complete uncomplicated resolution. As mentioned earlier, some children may develop hyperactive airways or become predisposed to recurrent croup. A few may develop subglottic stenosis caused by severe disease or prolonged intubation. Good hand washing and cleanliness can help decrease transmission from an infected patient, particularly at day care centers or even in the home environment. URIs are infections of the mouth, nose, throat, larynx (voice box), and trachea (windpipe). Upper respiratory infections include nasopharyngitis (common cold), sinusitis, pharyngitis, laryngitis, and laryngotracheitis. Nasopharyngitis (common cold) is a frequent cause of URIs, and most patients with this diagnosis with present with nasal congestion (80%). Nasopharyngitis rarely presents with a fever. Causes are predictably viral, and determining the exact viral pathogen is usually unnecessary. Treatment of the common cold is symptomatic, and hand washing is the best prevention. Sinusitis is a common diagnosis seen in primary care. The diagnosis and differentiation between bacterial and viral sinusitis is made clinically, based on the history and examination. Augmentin is the IDSA-preferred antibiotic for empiric treatment of bacterial sinusitis. Nasal steroids are highly effective for both viral and bacterial acute sinusitis. Identifying the cause of pharyngitis, especially GABHS, is important in helping prevent potential life-threatening complications. GAS pharyngitis accounts for 15% to 30% of infections in children and 5% to 15% in adults. The Centor criteria are useful prediction rules for the evaluation and management of possible GAS pharyngitis. Penicillins are the drugs class of choice for streptococcal pharyngitis. LTB is an infectious-induced inflammatory condition affecting the larynx, trachea, and bronchi. It occurs most often in children ages 6 months to 6 years, the peak age being 2 years. Recommended imaging for suspected croup includes anteriorposterior views of the neck, which show edematous subglottic walls converging to create a characteristic "steeple sign." The cornerstone of LTB medical management is nebulized epinephrine and dexamethasone. The effect of hand hygiene on illness rate among students in university residence halls Effect of a comprehensive infection control program on the incidence of infections in long-term care facilities Hand washing and hand disinfection Disinfection, sterilization and antisepsis: Grief principles and practices in healthcare facilities Treatment of the common cold Treating the common cold; an expert panel consensus recommendations for primary care providers The common cold in children Antibiotic use in acute upper respiratory tract infections Vital Health Stat 10 2009. National Center for Health Statistics. Available at: www.cdc.gov/nchs/data/series/sr_10/sr10_242 Acute rhinosinusitis in adults Role of antibiotics in sinusitis IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults American College of Physicians -American Society of Internal Medicine. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background Health care guideline: diagnosis and treatment of respiratory illness in children and adults Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials Intranasal corticosteroids in the treatment of acute rhinosinusitis Judicious antibiotic use and intranasal corticosteroids in acute rhinosinusitis Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America Management of Group A beta-hemolytic streptococcal pharyngitis Antimicrobial resistance of 914 beta-hemolytic streptococci isolated from pharyngeal swabs in Spain: results of a 1-year (1996-1997) multicenter surveillance study. The Spanish Surveillance Group for Respiratory Pathogens Bates' guide to physical examination and history taking The 5-minute clinical consult Acute bronchiolitis and croup Emergent management of croup A comparison of nebulized budesonide and intramuscular and oral dexamethasone for treatment of croup Croup: an overview