#54: Upper Respiratory Infections: Coughs, colds, gargling, and antibiotic underuse?!

August 28, 2017 | By Matthew Watto, MD

Don’t miss life threatening upper respiratory infections, and stop underusing antibiotics with tools and tips from our wonderful guests: Dr. Robert Centor, Professor of Medicine at University of Alabama, known for developing the Centor Criteria for pharyngitis, and his excellent blog and Twitter feed @medrants; and Dr. Alexandra Lane, Assistant Professor of Medicine, and Director of the Resident Clinic at Cooper University Hospital. We cover red flag signs in upper respiratory tract infections, diagnostic testing, physical exam maneuvers, antibiotic therapy, and symptom management. Plus, we’ll teach you have to counsel patients about upper respiratory infections and recommend some great learning resources.

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Case from Kashlak Memorial Hospital: 39 yo F with obesity, hypertension, fibromyalgia who presents with 3 days of chills, subjective fevers, sinus pressure/congestion, post-nasal drip, and cough with some green/yellow mucus. She says, “I get this every year and it only goes away with antibiotics. They usually give me a z-pack”.

Clinical Pearls:

1. Caution! These pearls apply to immunocompetent adult patients without chronic lung disease!
2. Upper respiratory infection: acute infection of upper airways. Commonly classified as sinusitis (rhinosinusitis), pharyngitis, laryngitis, and bronchitis. Overlap symptoms often present. [John Hopkins Abx Guide].
3. Rigors = uncontrollable, shaking chills often accompanied by fevers, or drenching sweats. Red flag! Subjective “chills” are less worrisome. (Dr. Centor says so!)
4. Patient counseling: Manage patient expectations about symptom duration (see below) and counsel them on red flag signs (see below). Write a prescription from the CDC to help patient understand diagnosis and treatment.
5. Symptom duration: Common cold = up to two weeks. Pharyngitis = 3-5 days. Rhinosinusitis = 3-4 weeks. Bronchitis = cough lasts up to 6-8 weeks.
6. Color of sputum, or sinus drainage does not differ in viral and bacterial infections [John Hopkins Abx Guide].
7. Scalene muscle: Palpate with thumb between heads of sternocleidomastoid on lateral neck. Quivering suggests accessory muscle use!
8. Red flag symptoms in sinusitis: Symptoms for more than 7 days and GETTING WORSE; “Double sickening” = symptoms of viral URI for 3-5 days resolve, but then worsen again; or high fevers with facial pain, purulent nasal discharge for 3 or more days (Ann Intern Med 2016). Treatment = amoxicillin-clavulanic acid 5-7 days (IDSA). Doxycycline, or fluoroquinolone are 2nd line.
9. Red flag symptoms in bronchitis: These 6 symptoms suggest pneumonia: Absent rhinorrhea, breathlessness, crackles, decreased breath sounds, tachycardia >100 bpm, fever >100.4F (38C). Low, intermediate, and high risk when 0, 1-2, or >=3 present (BMJ 2013).  Check chest xray if high risk.
10. Centor criteria: History of fever (especially at home). Lack of cough. Tender anterior cervical adenopathy. Tonsillar exudates. Test for strep in adults if 3 or more criteria met.
11. Pharyngitis in adolescents and young adults: Symptoms usually improve in 3-5 days. Differential: Viral, group A, C, or G Strep, Fusobacterium necrophorum (GN anaerobe). Strep test only tests group A, not group C, or G. Treatment: Consider empiric penicillin, or amoxicillin if >=3 Centor Criteria (Dr. Centor’s expert opinion). IDSA 2012 recommends treat only if positive strep test.
12. Lemierre’s syndrome: Pharyngitis complicated by suppurative thrombophlebitis of internal jugular vein with risk for septic emboli to brain, lungs, joints, etc. Treatment is IV antibiotics and NOT anticoagulation.
13. Steroids for pharyngitis: NNT=12 to shorten symptoms by 24 hours. Study power too low to detect risk serious adverse events. Dr. Centor is not a fan.
14. Symptom  management for URI: Modest (level 2) evidence for all of the following: zinc acetate lozenges (cold), ipratropium nasal spray (cough, rhinorrhea), combination sedating antihistamine/decongestant (cough, congestion), topical decongestant (congestion), guaifenesin (cough), dextromethorphan (cough), NSAIDS (sore throat), acetaminophen (sore throat). Target therapy to main symptoms e.g. cough vs rhinorrhea, vs congestion vs sore throat. Nonsedating antihistamine (e.g. loratadine) lack anticholinergic effects and aren’t helpful for infections.
15. Duration of antibiotic therapy: For adult pharyngitis use at least 7 days of antibiotics. For community acquired pneumonia it’s okay to stop antibiotics on day 5 if stable/improved symptoms on day 3.
16. Alternative medicine: Gargling with water 3 times daily lower incidence of URI by 40% (J Prev Med 2005). Honey as effective as guaifenesin, safe in kids >1yo, and tasty (AAFP article)! Insufficient evidence for heated, humidified air. Echinacea, and Vitamin C ineffective for treatment/prevention.

Goal: Listeners will avoid diagnostic errors, avoid antibiotic UNDERUSE (yes, underuse), and select appropriate evidence based therapy for upper respiratory tract infections.

Learning objectives:
After listening to this episode listeners will…

1. Define and classify types of “respiratory tract infections” or “URIs”
2. Identify patients who may benefit from diagnostic testing
3. Recall that sputum characteristics are largely meaningless
4. Differentiate between URIs, and allergic or nonallergic rhinitis
5. Identify who needs a chest x ray
6. Provide patients counseling on expectation management and natural course of common upper respiratory infections
7. Recall the evidence for alternative therapies like zinc tablets, Vitamin C, steam, gargling water
8. Identify limited evidence for symptom management
9. List conditions that require antibiotic or antiviral therapy
10. Identify patients who require antimicrobial therapy

Disclosures: Dr. Centor and Dr. Lane report no relevant financial disclosures for this discussion.

Links from the show:

1. The Babadook (film) by Jennifer Kent
2. The Alchemist (book) by Paulo Coehlo
3. FaceApp on iTunes
4. Harry Bosch series (books) by Michael Connelly
5. How to talk so your kids will listen and listen so your kids will talk (book) by Adele Faber, and Elaine Mazlish
6. “Diagnostician” blog post KevinMD by Dr. Robert Centor
7. Length of antibiotic therapy by Dr. Robert Centor
8. Comment on use of steroids for pharyngitis by Dr. Robert Centor Jan 31, 2010.
9. How to use nasal sprays (handout)
10. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Annals Intern Med 2016
11. CDC Prescription Pad for ARTI
12. The diagnosis and treatment of cough. NEJM 2000
13. Honey for Acute Cough in Children (article) AAFP.org 2016
14. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Review 2014.
15. The effectiveness of high dose zinc acetate lozenges on various common cold symptoms: a meta-analysis. BMC Fam Pract 2015
16. Nasal decongestants in monotherapy for the common cold. Cochrane Database of Systematic Reviews 2016.
17. Management of patients with respiratory infections in primary care: procalcitonin, C-reactive protein or both? Expert Rev Resp Med 2015
18. Use of serum C reactive protein and procalcitonin concentrations in addition to symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough: diagnostic study BMJ 2013
19. Prevention of upper respiratory tract infections by gargling: a randomized trial. Am J Prev Med 2005
20. Effectiveness and safety of intranasal ipratropium bromide in common colds. A randomized, double-blind, placebo-controlled trial. Annals Intern Med 1996
21. Upper respiratory infection (URI) in adults and adolescents. Dynamed Plus accessed 08-14-2017
22. Corticosteroids for the common cold. Cochrane Database Systematic Reviews 2015