Common cold and acute upper respiratory tract infection

Essential Evidence

Updated: 2020-02-17

Overall Bottom Line

  • The diagnosis of upper respiratory tract infection (RTI) is based on clinical signs and symptoms. This is an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms are present, but not prominent. SORT B
  • Antibiotics are ineffective for the treatment of the common cold in children and adults. Delayed prescriptions greatly reduce the likelihood of antibiotic consumption and reduce the likelihood of return visits as well, compared to immediate prescriptions. SORT A
  • Antihistamines early in symptom course and multiple doses of decongestants may provide symptom relief in adults. SORT B
  • The mean duration of illness is 7 to 14 days; most patients feel better within the first week. However, cough may persist for up to 3 weeks. SORT C

Background

Background

Nonspecific upper respiratory infection (URI) is typically viral in origin and presents with symptoms that are referred to as the common cold. Clinical features include headache, sneezing, sore throat, rhinorrhea, malaise, and cough.

Incidence

  • Children: 6 to 8 common colds per year.
  • Adults: 2 to 4 common colds per year.

Economic Impact

  • The annual cost for antibiotic prescriptions for URIs is $227 million.

Other Impact

  • The common cold causes approximately 20 million lost work days and 21 million lost school days.
  • There are 25 million ambulatory care visits annually for URIs.

Causes of the Condition

  • Rhinoviruses are the most common cause. Other viral causes include coronavirus, influenza virus, respiratory syncytial virus, parainfluenza virus, adenovirus, and enterovirus.

Pathophysiology

  • Various respiratory viruses have different mechanisms that lead to common cold symptoms.
  • Our understanding of the pathophysiology of the common cold comes from studying the rhinovirus.
  • The virus infects nasal mucosa or eyes through direct contact or aerosolized particles.
  • Infection of the nasal mucosa leads to vasodilation and increased vascular permeability, which leads to nasal obstruction and rhinorrhea.
  • Stimulation of the mucous glands also leads to rhinorrhea.
  • Inflammatory mediators contribute to malaise, headache, and myalgia.

Prevention

Screening and Prevention

Secondary Prevention

  • In a meta-analysis of 6 case-control studies, physical measures that were effective in preventing the spread of severe acute respiratory syndrome (SARS) were handwashing more than 10 times daily (OR = 0.45; 95% CI, 0.36-0.57; NNT = 4), wearing masks (OR = 0.32; 95% CI, 0.25-0.40; NNT = 6), wearing N95 masks (OR = 0.09; 95% CI, 0.03-0.30; NNT = 3), wearing gloves (OR = 0.43; 95% CI, 0.29-0.65; NNT = 5), wearing gowns (OR = 0.23; 95% CI, 0.14-0.37; NNT = 5), and handwashing, masks, gloves, and gowns combined (OR = 0.09; 95% CI, 0.02-0.35; NNT = 3). 1
  • High-dose vitamin D does not reduce wintertime URIs in healthy children. [poem]53

Diagnosis

Diagnosis

Bottom Line

  • The diagnosis of upper RTI (common cold) is used when there is an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms are present, but not prominent. SORT B 2
  • Purulent nasal discharge or sputum does not predict bacterial infection or benefit from antibiotics. SORT A [poem]3
  • Respiratory viral testing should not be ordered for healthy, immune-competent children presenting with typical viral RTI symptoms; diagnosis should be made clinically. SORT C 52

Differential Diagnosis

DiagnosisFeatures
Acute rhinosinusitisUpper RTI symptoms that have not improved after 10 days or worsen after 5 days
Streptococcal pharyngitisFever, tonsillopharyngeal erythema and exudates, anterior cervical adenopathy, absence of cough
InfluenzaAbrupt onset of constitutional and respiratory symptoms, particularly accompanied by myalgias and fatigue
Otitis mediaBulging, limited mobility, and erythema of tympanic membrane; air-fluid level or bubbles of air may be visible; otorrhea; distinct otalgia
PneumoniaFever, tachypnea, tachycardia, abnormal chest examination, or abnormal chest x-ray

Using the History and Physical

  • The diagnosis of upper RTI is based on clinical signs and symptoms. This is an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms are present, but not prominent. 2
  • Purulent nasal discharge or sputum occurs when inflammatory cells or sloughed mucosal epithelial cells are present. 2
  • Eighty percent to 90% of patients with the common cold develop purulent rhinitis. [poem]3

Selecting Diagnostic Tests

  • Diagnostic tests are not indicated.
  • Patients with signs and symptoms suggestive of a more severe infection (e.g., tachypnea, purulent sputum, or hemoptysis) should have a chest radiograph or other testing as clinically indicated.
  • CBC with differential is not a reliable way to distinguish viral from bacterial URI.

Approach to the Patient

  • See algorithm in Figure 01 for evaluation of patients who are otherwise healthy.
  • Patients with risk factors for increased severity of disease (infants, the elderly, smokers, those with chronic disease, and those who are immunocompromised) should consult a health care provider.

History and Physical Tests

Diagnostic Tests

Treatment

Treatment

Bottom Line

  • Antibiotics are ineffective for the treatment of the common cold in children and adults. SORT A [cochrane]15
  • Multiple doses of nasal decongestant may be effective for the short-term relief of congestion in adults. Evidence is insufficient to assess the effectiveness of a single dose. SORT B [cochrane]36
  • Antihistamines may reduce overall severity of symptoms in adults during the first two days of use. There is no evidence of effectiveness of antihistamines in children. SORT B [cochrane]37
  • Antihistamine-analgesic-decongestant combinations have some general symptomatic benefit in adults and older children. There is no evidence of effectiveness in young children. [cochrane]56 SORT B
  • Dextromethorphan is effective for cough in adults. SORT B 16

Drug Therapy

  • Patients with the common cold who received antibiotics did no better with respect to cure or persistence of symptoms than those given placebo. [cochrane]15Delayed antibiotic prescriptions (either provide at the time of visit, or available on return without an appointment, and time-limited) reduce the number of antibiotic prescriptions filled (31% vs 93%) with little if any impact on satisfaction and no increase in harms. [cochrane]43
  • Intranasal corticosteroids do not seem to provide symptomatic relief, but evidence is limited and of poor quality. [cochrane]35
  • Multiple doses of nasal decongestant may be effective for the short-term relief of congestion in adults. Evidence is insufficient to assess the effectiveness of a single dose. [cochrane]36
  • Antihistamines may reduce overall severity of symptoms in adults during the first to days of use. There is no evidence of effectiveness of antihistamines in children. [cochrane]37
  • An inhaled anticholinergic ipratropium bromide is effective for cough suppression in adults. 17
  • Dextromethorphan is effective for cough in adults. 16
  • Acetaminophen may help relieve rhinorrhea and nasal obstruction but does not appear to help with other cold symptoms. [cochrane]38
  • Naproxen has beneficial effects on the symptoms of headache, malaise, myalgia, and cough. 18 This is consistent with findings from a Cochrane review of 9 NSAID trials that demonstrated significant benefit for headache, ear pain, and muscle and joint pain (related to the analgesic effects of NSAIDs); there was borderline benefit on malaise, and no benefit on cough or rhinorrhea. [cochrane]19

Complementary/Alternative Therapy

  • Vitamin C prophylaxis may decrease the duration and severity of the symptoms, but supplementation did not reduce the incidence of the common cold with the exception of those participating in severe exercise or exposed to cold environments. [cochrane]20
  • A systematic review of 25 randomized controlled trials demonstrated that supplementation with Vitamin D was safe and protected against acute RTI overall in children and adults. 40
  • Heated, humidified air may help to reduce symptoms, but studies are inconsistent. [cochrane]21 In a randomized trial of 889 patients at least 3 years of age, advice to use steam inhalation with or without regular or as-needed analgesic dosing did not improve symptoms. 33
  • Two systematic reviews found that zinc administered within 24 hours of the onset of cold symptoms reduces the duration and severity in healthy adults. 41 [poem]31
  • Preparations based on aerial parts from Echinacea purpurea may be effective for early treatment but research results are not consistent. Other echinacea preparations have not been proven to be of benefit. [cochrane]22
  • In a meta-analysis, ginseng (when taken for 8-16 weeks) significantly shortened the duration of colds by 6.2 days (2 trials; 95% CI, 3.4-9.0). 23
  • A Cochrane review found insufficient evidence to support use of garlic in preventing or treating the common cold; one trial supported its role in prevention. [cochrane]34
  • Probiotics may be more beneficial than placebo in preventing upper RTI in adults and children, as well as in reducing duration of acute upper RTI episodes, antibiotic use, and school absences due to common cold. [cochrane]42
  • Small trials indicate saline nasal irrigation may relieve the symptoms of acute upper RTI. [cochrane]50

Behavioral Medicine and Psychotherapy

  • Delayed prescription reduces use of antibiotics and does not decrease patient satisfaction. [cochrane]43
  • Patient and public education interventions are effective in reducing antibiotic prescribing. [cochrane]44 45
  • Clinician empathy (defined as perfect score on an empathy scale), as perceived by patients with a common cold, decreased cold duration (by about 1 day) and severity; it was also positively associated with increased cytokine interleukin-8. 24

Other Treatment

  • There is no clear evidence of benefits or harms with the use of heated water vapour or steam for patients with the common cold or acute upper respiratory infections, based on 6 trials with 387 participants. [cochrane]54

Management of Complications

  • Infection of the upper respiratory tract may lead to eustachian tube dysfunction, which plays a role in acute otitis media. 47
  • Infection may trigger asthma exacerbations in children and adults. 46
  • Infection may trigger chronic obstructive pulmonary disease exacerbations. 48
  • Approximately 8% of cases of the common cold are complicated by acute bacterial sinusitis in young children. 49

Prognosis

Prognosis

Bottom Line

  • The mean duration of the common cold is 7 to 14 days; most patients feel better within the first week. SORT C 2
  • Cough may persist up to 3 weeks. SORT C 25 32 [poem]55

Natural History

  • Self-limited disease.
  • The mean duration of the common cold is 7 to 14 days; most patients feel better within the first week. 2
  • Cough may persist up to 3 weeks in adults and children [poem]55; consider pertussis for persistent cough. 25

Prognosis

  • The prognosis and natural history are the same.

Follow-up tests and monitoring

  • None recommended.

Advice for patients

  • Advise the patient to contact a health care provider if symptoms do not improve after 10 days or worsen after 5 days.
  • Educate patients about the differences between viral and bacterial infections.
  • Discuss good hygiene (e.g., patients should cover their mouth and nose while coughing and wash hands to prevent transmission). Recommend coughing inside the elbow, which will avoid hand contamination.
  • Discuss the dangers of antibiotic overuse and resistance.

Special Populations

Management of Special Populations

The Elderly

  • In a randomized controlled trial of 1072 adults with a mean age of 76 years, the group taking a fermented probiotic (Lactobacillus casei) for 3 months had upper respiratory infections that were 3 days shorter in duration than the group taking placebo, with no difference in the overall number of URIs or adverse events. The mechanism of action is unclear. [poem]30

Pregnancy

  • Pregnancy risk categories for commonly used medications: 
    • Acetaminophen—B
    • Dextromethorphan—C
    • Chlorpheniramine—B
    • Ipratropium—B
    • Guaifenesin—C
    • Naproxen—B in first and second trimester. D in third trimester. Should be used sparingly because of possibility of adverse effects on fetus
    • Oxymetazoline—C
    • Pseudoephedrine—B

Infants and Children

  • Antitussives and antihistamines are not effective for symptomatic relief. [cochrane]26 [cochrane]37
  • Antihistamine-analgesic-decongestant combinations have some general benefit older children. There is no evidence of effectiveness in young children. [cochrane]56
  • In children between the ages of 2 and 11 years with URI symptoms for at least 7 days, application of vapor rub improved symptom scores and children and parents’ ability to sleep compared to petrolatum or placebo. [poem]29
  • A single dose of honey can reduce cough severity and sleep disturbance in children; it should not be given to infants because of the risk of botulism. [poem]27
  • Nasal decongestants can not be recommended. [cochrane]36
  • Acetaminophen is effective for fever reduction. 39
  • Nasal suctioning in infants may relieve congestion. 51

References and Links

References and Links

Authors

Scott E. Nass, MD, MPA, FAAFP, AAHIVS, Director of Inpatient Education, Family Medicine Residency Program, Citrus Valley Health Partners;
Aaron J. Morgan, MD, Associate Professor, Department of Dermatology, New Jersey Medical School;
David M. Wong, DO, Associate Program Director, Family Medicine Residency, Department of Family Medicine, Arrowhead Regional Medical Center

Editors

Kenny Lin, MD, MPH, Professor of Family Medicine, Georgetown University
Mindy A. Smith, MD, MS, Clinical Professor, Department of Family Medicine, Michigan State University

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