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”.
Caution! These pearls apply to immunocompetent adult patients without chronic lung disease!
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].
Rigors = uncontrollable, shaking chills often accompanied by fevers, or drenching sweats. Red flag! Subjective “chills” are less worrisome. (Dr. Centor says so!)
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.
Symptom duration: Common cold = up to two weeks. Pharyngitis = 3-5 days. Rhinosinusitis = 3-4 weeks. Bronchitis = cough lasts up to 6-8 weeks.
Color of sputum, or sinus drainage does not differ in viral and bacterial infections [John Hopkins Abx Guide].
Scalene muscle: Palpate with thumb between heads of sternocleidomastoid on lateral neck. Quivering suggests accessory muscle use!
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.
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.
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.
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.
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.
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.
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.
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.
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…
Define and classify types of “respiratory tract infections” or “URIs”
Identify patients who may benefit from diagnostic testing
Recall that sputum characteristics are largely meaningless
Differentiate between URIs, and allergic or nonallergic rhinitis
Identify who needs a chest x ray
Provide patients counseling on expectation management and natural course of common upper respiratory infections
Recall the evidence for alternative therapies like zinc tablets, Vitamin C, steam, gargling water
Identify limited evidence for symptom management
List conditions that require antibiotic or antiviral therapy
Identify patients who require antimicrobial therapy
Disclosures: Dr. Centor and Dr. Lane report no relevant financial disclosures for this discussion.