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  • URIs are among the leading causes of lost time from work or school.

  • Distinguishing pts with primary viral URI from those with primary bacterial URI is difficult since the signs and symptoms are the same.

  • URIs are often treated with antibiotics even though bacteria cause only 25% of cases. Inappropriate prescribing of antibiotics for URIs is a leading cause of antibiotic resistance in common community-acquired pathogens such as Streptococcus pneumoniae.


  • Definition: Nonspecific URIs (the “common cold”) have no prominent localizing features.

  • Etiology: A wide variety of viruses (e.g., rhinoviruses, coronaviruses, parainfluenza viruses, influenza viruses, adenoviruses) can cause nonspecific URIs.

  • Clinical manifestations: an acute, mild, self-limited catarrhal syndrome, typically characterized by rhinorrhea, nasal congestion, cough, and sore throat

    • Hoarseness, malaise, sneezing, and fever are more variable.

    • The median duration of symptoms is ∼1 week (range, 2–10 days). Cough secondary to upper respiratory inflammation may last 2–3 weeks and does not necessarily indicate a need for antibiotics.

    • Secondary bacterial infections complicate 0.5–2% of colds and are associated with a prolonged course and/or increased severity of illness, often with localization of signs and symptoms. Purulent nasal and throat secretions are poor predictors of bacterial infection.

  • Treatment: Symptom-based treatment (e.g., with decongestants, NSAIDs) is typically all that is required. Antibiotics are not indicated.


  • Rhinosinusitis is an inflammatory condition most commonly involving the maxillary sinus; next, in order of frequency, are the ethmoid, frontal, and sphenoid sinuses.

  • Sinusitis accounts for millions of visits to primary care physicians each year and is the fifth most common diagnosis for which antibiotics are prescribed.


  • Definition: sinusitis of <4 weeks’ duration

  • Etiology: Infectious and noninfectious causes lead to sinus ostial obstruction and retention of mucus.

    • Infectious causes include viruses (e.g., rhinovirus, parainfluenza virus, influenza virus) and bacteria (e.g., S. pneumoniae, nontypable Haemophilus influenzae, and—in children—Moraxella catarrhalis).

      • In immunocompromised pts, fungi (e.g., Rhizopus, Mucor, and occasionally Aspergillus) can be involved.

      • Nosocomial cases are often polymicrobial and involve Staphylococcus aureus and gram-negative bacilli.

    • Noninfectious causes include allergic rhinitis, barotrauma, and exposure to chemical irritants.

  • Clinical manifestations: Common manifestations include nasal drainage and congestion, facial pain or pressure, and headache.

    • Tooth pain and halitosis can be associated with bacterial sinusitis.

    • Pain localizes to the involved sinus and is often worse when the pt bends over or is supine.

    • Advanced frontal sinusitis can present as Pott’s puffy tumor: swelling and pitting edema over the frontal bone from a communicating subperiosteal abscess.

    • Life-threatening complications include meningitis, epidural abscess, and brain abscess.

  • Diagnosis: It is difficult to distinguish viral from bacterial sinusitis clinically, although viral cases greatly outnumber bacterial cases.

    • Only 40–50% of pts with symptoms of >10 days’ duration, purulent nasal drainage, nasal obstruction, and facial pain have bacterial sinusitis.

    • If fungal sinusitis is a consideration, ...

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