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COMMON COLDS/UPPER RESPIRATORY TRACT INFECTIONS
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ESSENTIALS OF DIAGNOSIS
Sore throat, congestion, low-grade fever, mild myalgias, and fatigue.
Symptoms lasting for 12–14 days.
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General Considerations
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Although colds are mild, self-limiting, and short in duration, they are a leading cause of sickness in industrial and school absenteeism. Each year, colds account for 170 million days of restricted activity, 23 million days of school absence, and 18 million days of work absence.
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Most colds are caused by viruses. Rhinoviruses are the most common type of virus and are found in slightly more than half of all patients. Coronaviruses are the second most common cause. Rarely (0.05% of all cases) can bacteria be cultured from individuals with cold symptoms. It is not clear whether these bacteria cause the cold, are secondary infectious agents, or are simply colonizers. Bacterial pathogens that have been identified include Chlamydia pneumoniae, Haemophilus influenzae, Streptococcus pneumoniae, and Mycoplasma pneumoniae.
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The mechanisms of transmission suggest that colds can be spread through contact with inanimate surfaces, but the primary transmission appears to be via hand-to-hand contact. The beneficial effects of removing viruses from the hands are supported by observations that absences of children have been reduced through the use of antiseptic hand wipes throughout the day at school or daycare.
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Colds generally last 12–14 days. Reassurance and education to patients reduces misconceptions that symptoms lasting >1 week are abnormal. When the symptoms of congestion persist longer than 2 weeks, other causes of chronic congestion should be considered (Table 28-1).
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Symptoms of colds include sore throat, congestion, low-grade fever, and mild myalgias and fatigue. In general, early in the development of a cold the discharge is clear. As more inflammation develops, the discharge takes on some coloration. A yellow, green, or brown-tinted nasal discharge is an indicator of inflammation, not secondary bacterial infection. Discolored nasal discharge raises the likelihood of sinusitis, but only if other predictors of sinusitis are present. Therefore education to patients and reassurance is needed, and not reflexive antibiotic prescriptions, which some patients ultimately desire.
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Primary complications from upper respiratory tract infection are otitis media and sinusitis. These complications develop from obstruction of the eustachian tube or sinus ostia from nasal passage edema. Although treatment of these infections with antibiotics is common, the vast majority of infections clear without antibiotic therapy.
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One misconception is that using antibiotics during the acute phase of a cold can prevent these complications. Evidence shows that taking antibiotics during a cold does not reduce the incidence of sinusitis or otitis media. Nor do antibiotics give a faster recovery than placebos.
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Differential Diagnosis
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The differential diagnosis of colds includes complications of the cold such as sinusitis or otitis media, acute bronchitis, and noninfectious rhinitis. Influenza shares many of the symptoms of a common cold, but generally patients have a much higher fever, myalgias, and more intense fatigue.
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Despite the widespread recognition that viruses cause common colds, several studies have shown that patients with the common cold who are seen in physicians’ offices are often treated with antibiotics. The prescribing of antibiotics for colds occurs more often in adults than children. Although this practice appears to have declined in adults, the use of broad-spectrum antibiotics for colds is still common in children. The need to reduce the use of antibiotics for viral conditions has important ramifications on communitywide drug resistance; in areas in which prescribing antibiotics for respiratory infections has been curtailed, reversals in antibiotic drug resistance have been observed.
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Currently, the most effective treatment is symptom reduction with over-the-counter (OTC) decongestants, the most popular of which include pseudoephedrine hydrochloride and topically applied vasoconstrictors. These agents produce short-term symptomatic relief. However, patients must be warned to use topical agents for a limited duration because prolonged use is associated with rebound edema of the nasal mucosa (rhinitis medicamentosa).
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Several OTC medications contain a mix of decongestants, cough suppressants, and pain relievers. Again, the use of these preparations will not cure the common cold but will provide symptomatic reduction and relief.
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Antihistamines, with a few exceptions, have not been shown to provide effective treatment. Zinc gluconate lozenges are available without a prescription, but a meta-analysis of 15 previous studies on zinc concluded that zinc lozenges were not effective in reducing the duration of cold symptoms.
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Some herbal remedies are useful for treatment of the common cold. Echinacea, also known as the “American coneflower,” has been purported to reduce the duration of the common cold by stimulating the immune system; however, evidence for its efficacy is mixed. Echinacea should be used for only 2–3 weeks to avoid liver damage and other possible side effects that have been reported during long-term use of this herb. Ephedra, also known as ma huang, has decongestant properties that make it similar to pseudoephedrine. Ephedra is more likely than pseudoephedrine to cause increased blood pressure tachyarrhythmia. This is especially true if used in conjunction with caffeine.
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Linde
K
et al.. Echinacea for preventing and treating the common cold.
Cochrane Database Syst Rev. 2006;(2):CD000530.
[PubMed: 16437427]
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Mainous
AG
3rd
et al.. Trends in antimicrobial prescribing for bronchitis and upper respiratory infections among adults and children.
Am J Public Health. 2003;93:1910.
[PubMed: 14600065]
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ESSENTIALS OF DIAGNOSIS
“Double-sickening” phenomenon.
Maxillary toothache and purulent rhinorrhea.
Poor response to decongestants.
History of discolored nasal discharge.
Facial pain/pressure/fullness; increasing pain with bending forward
Nasal congestion
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General Considerations
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Sinusitis is most often a complication of an upper respiratory viral infection, so the incidence peaks in the winter cold season. Medical conditions that may increase the risk for sinusitis include cystic fibrosis, asthma, immunosuppression, and allergic rhinitis. Cigarette smoking may also increase the risk of bacterial sinusitis during a cold because of reduced mucociliary clearance.
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Most cases of acute sinusitis are caused by viral infection. The inflammation associated with viral infection clears without additional therapy. Bacterial superinfection of upper respiratory infections (URIs) is rare and occurs in only 0.5–1% of colds. Fungal sinusitis is very rare and usually occurs in immunosuppressed individuals or those with diabetes mellitus.
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Acute sinusitis has considerable overlap in its constellation of signs and symptoms with URIs. One-half to two-thirds of patients with sinus symptoms seen in primary care are unlikely to have sinusitis. URIs are often precursors of sinusitis, and at some point symptoms from each condition may overlap. Sinus inflammation from a URI without bacterial infection is also common.
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The signs and symptoms that increase the likelihood that the patient has acute sinusitis are a “double-sickening” phenomenon (whereby the patient seems to improve following the URI and then deteriorates), maxillary toothache, purulent nasal discharge, poor response to decongestants, and a history of discolored nasal discharge. Also on examination, patients will have tenderness to palpation of their sinuses and worsening pain with bending forward.
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Nonsevere symptoms, such as mild pain and afebrile state of <7 days’ duration should be treated with supportive care. Treatment would include analgesics, decongestants, and saline nasal irrigation. Narrow-spectrum antibiotics should be reserved for patients with no improvement in 7 days or worsening symptoms. No radiologic imaging is required. A rare complication of sinusitis to be aware of is orbital and/or intracranial bony involvement. If symptoms fail to improve with therapy course, consider referral to ENT. The effectiveness of antibiotics is unclear. Amoxicillin/clavulanate acid (ACA) is preferred over amoxicillin alone in treatment of children and adults, provided the patient is not allergic to the components. High doses of ACA at 90 mg/kgm daily in BID dosing is recommended for regions with >10% endemic rate of sinusitis, severe infection, children who attend daycare, a child <2 years old, an adult aged > 65 years, a recently hospitalized patient, any recent antibiotic use, or if a patient is immunocompromised. There are increasing rates of resistance to macrolides and septra and should not be used for empiric therapy. Alternatives if with allergy to ACA would be doxycycline, or levoflox/moxifloxacin. Treatment should be for 5–7 days for adults and 10–14 days for children on antibiotics for sinusitis.
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Acute rhinosinusitis in adults. Am Acad Fam Physicians. 2011; 83(9):1057–1063.
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Infectious Diseases Society of America (IDSA). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012 54(8):e72–e112.
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American Academy of Pediatrics. Subcommittee on Management of Sinusitis and Committee on Quality Improvement: clinical practice guideline: management of sinusitis.
Pediatrics. 2001;108:798.
[PubMed: 11533355]
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Williams
JW
Jr
et al.. Antibiotics for acute maxillary sinusitis.
Cochrane Database Syst Rev. 2000;(2):CD000243.
[PubMed: 12804392]
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ESSENTIALS OF DIAGNOSIS
High fever.
Extreme fatigue.
Myalgias.
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Diagnosis, treatment, and prevention of influenza in children are reviewed extensively in Chapter 5.
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General Considerations
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Although most cases of the flu are mild and usually resolve without medical treatment within 2 weeks, some will develop complications. Currently, three types of viruses causing influenza have been identified in the United States: A, B, and C. Seasonal epidemics from influenza types A and B are seen every winter. Type C influenza usually causes a mild respiratory illness and is not responsible for epidemics. If a new strain emerges and infects a population, an influenza pandemic can result.
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Influenza A is identified by two proteins on the virus surface: a hemagglutinin (H) and a neuraminidase (N). These proteins result in 16 different H subtypes and 9 different N subtypes. The A form of influenza can be further divided into strains. The two subtypes of influenza A found in humans currently are A(H1N1) and A(H3N2). In 2009, an influenza pandemic occurred when a very different strain of influenza A(N1H1) developed in humans. The influenza B is broken down by different strain, but not by subtypes.
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Vaccination is the most effective prevention against influenza. The seasonal flu vaccination is a trivalent vaccine with each component selected to protect against one of the three main groups of influenza viruses circulating in humans. The influenza viruses in the seasonal flu vaccine are selected each year from surveillance-based forecasts about which viruses are most likely to cause illness in the upcoming season. The World Health Organization (WHO) recommends specific vaccine viruses for inclusion, but each country decides independently which strains should be included. The US Food and Drug Administration (FDA) determines which vaccine viruses will be used in US-licensed vaccines. Influenza vaccinations require annual dosing for adults and children aged >1 year. Therefore, the influenza vaccine does not cover all strains of the influenza virus, and patients who have received their annual vaccination can still develop influenza; this is an important education point for all patients. A complete listing of who should be immunized can be found on the Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) website and others.
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The spread of influenza is from person to person by sneezing or coughing. Therefore, everyday care to stay healthy can help prevent contracting the flu and/or spreading the flu to others. Simple steps, such as covering nose and mouth when sneezing or coughing with a tissue; avoiding touching mouth, nose, and eyes if sick; washing hands frequently with soap or germicide solution; and staying home if sick to avoid others, may help prevent the spread of influenza. Additionally, if a patient has been exposed to influenza by another, influenza antiviral prescription drugs can be used as chemoprophylaxis of influenza.
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The flu can last from 3 days to 2 weeks. Mild cases may be assumed to have the common cold and receive no medical treatment. Symptoms include high fever, extreme fatigue, and myalgias. Other symptoms associated with the flu include sore throat, rhinorrhea, cough, headache, and chills. Some people experience nausea, vomiting, and diarrhea. The diagnosis is most commonly clinical, but there are laboratory confirmation tests available with rapid influenza diagnostic tests (RIDTs), viral cultures, and immunoflourescence, and reverse transcription-PCR. Clinicians should realize that a negative RIDT result does not exclude a diagnosis of influenza, as sensitivities are 40–70%. When there is a clinical suspicion of influenza and antiviral treatment is indicated, the treatment should be started without waiting for results of additional influenza testing.
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Complications can lead to hospitalization and even death. These complications include, but are not limited to, otitis media, sinusitis, acute bronchitis, and pneumonia. Exacerbations of chronic illnesses such as asthma, congestive heart failure, and chronic obstructive lung disease are further complications of the flu.
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Differential Diagnosis
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One must consider other viruses, such as the common cold viruses, which have many of the same symptoms in less severity.
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People who develop flu symptoms should seek medical treatment as soon as possible, especially those in the high-risk group, as shown in Table 28-2. If treatment with antivirals is begun within 48 hours of the first signs or symptoms of illness, the patient gets the greatest benefit. These benefits include shortening the illness by at least 24 hours, preventing serious complications, and decreasing the likelihood of spreading the disease to others. Treatment with oseltamivir or zanamivir is effective against all forms of human influenza, including A (H1N1)/(H3N2), 2009 A(H1N1), and B. Two older medications, amantadine and rimantadine, remain susceptible to influenza A but not to B. The CDC recommends the use of oseltamivir or zanamivir at this time, due to the emergence of the new strain of A (N1H1). Treatment guidelines differ for age groups and high-risk groups. Therefore, it is important when considering treatment options to refer to the Physician’s Desk Reference (PDR) to ensure that appropriate treatment is given. Symptomatic treatment can be given with an antipyretic for the fever and an anti-inflammatory for pain and myalgias.
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Centers for Disease Control and Prevention (CDC), Advisory Committee on Immunization Practices (ACIP).
Recommended Adult Immunization Schedule—United States 2011; Jan. 28 , 2011 (available at
http://www.cdc.gov/vaccines/pubs/ACIP-list.htm).
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Centers for Disease Control and Prevention [
MMWR, Recommendations and Reports 60(1), Jan. 21, 2011].
Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza. Recommendations of the Advisory Committee on Immunization Practices (
ACIP) (available at
www.cdc.gov/mmwr/pdf/rr/rr6601.pdf).