URTI

  1. Given an appropriate history and/or physical examination:
    1. Differentiate life-threatening conditions (epiglottitis, retropharyngeal abscess) from benign conditions.
    2. Manage the condition appropriately.
  2. Make the diagnosis of bacterial sinusitis by taking an adequate history and performing an appropriate physical examination, and prescribe appropriate antibiotics for the appropriate duration of therapy.
  3. In a patient presenting with upper respiratory symptoms:
    1. Differentiate viral from bacterial infection (through history and physical examination).
    2. Diagnose a viral upper respiratory tract infection (URTI) (through the history and a physical examination).
    3. Manage the condition appropriately (e.g., do not give antibiotics without a clear indication for their use).
  4. Given a history compatible with otitis media, differentiate it from otitis externa and mastoiditis, according to the characteristic physical findings.
  5. In high-risk patients (e.g., those who have human immunodeficiency virus infection, chronic obstructive pulmonary disease, or cancer) with upper respiratory infections: Look for complications more aggressively, and follow up more closely.
  6. In a presentation of pharyngitis, look for mononucleosis.
  7. In high-risk groups:
    1. Take preventive measures (e.g., use flu and pneumococcal vaccines).
    2. Treat early to decrease individual and population impact (e.g., with oseltamivir phosphate [Tamiflu], amantadine).

See Cough, Rhinosinusitis, Pharyngitis, Pneumonia, Acute Otitis Media.

Common Cold

  • Usual 1.5w course
  • Rule out
    • Sinusitis (PODS)
    • Acute Bronchitis (Persistent cough >3 weeks)
      • Consider antibiotics in ≥ 75 years, >3 weeks or suspect B. pertussis (Whooping cough, >3 weeks, vomiting (related to coughing), exposure to pertussis, not vaccinated)
  • Symptomatic therapy
    • Analgesics (Acetaminophen/NSAIDs)
    • Combination products (Antihistamine, decongestant, analgesics)
    • Consider Zinc lozenges 75mg PO daily, Pleragonium sidoides, Andrographis paniculata
      • Risk of irreversible anosmia in intranasal zinc preparations
    • Nasal symptoms
      • Nasal saline irrigation (poor evidence)
      • Intranasal cromolyn sodium 1 spray (5.2mg) in each nostril q2h PRN x 2 days then 4 times daily x 5 days
      • Intranasal ipratropium bromide 0.06% solution two sprays (42mcg/spray) in each nostril 3-4 times daily PRN x 4 days
    • Cough suppressant
      • Brompheniramine plus sustained-release pseudoephedrine
      • Ipratropium bromide inhaled
      • Dextromethorphan 30mg PO q6-8h PRN
  • Prevention
    • Handwashing
    • Flu vaccine (6mo-5yo, ≥65yo, chronic disease, pregnancy/postpartum, healthcare worker, frequent contact with above)
    • Pneumococcal 23-valent
      • ≥65 years old, or if specific risk factors
  • No evidence for antibiotics, echinacea, intranasal corticosteroids

Seasonal Influenza

  • Caused by influenza A or B viruses, mainly during winter

Treatment may reduce symptoms from 0.5-3 days (if started within 48h)

  • Zanamivir (Relenza) two inhalations (10mg) PO BID x 5d or oseltamivir (Tamiflu) 75mg PO BID x 5d
    • Amantadine not first-line due to high rates of resistance
    • May extend therapy in severely ill patients
  • Treatment with antiviral should be considered for the following patients
    • Severe disease (requiring hospitalization or evidence of lower respiratory tract infection, eg. dyspnea, tachypnea, oxygen desaturation)
    • High risk for complications (pregnancy)
  • Most efficacious within first 48h of illness, but indicated to treat if severe illnessor pregnancy

Indications to consider X-ray

  • Hemoptysis
  • Pleuritic chest pain
  • Dyspnea
  • Systemic symptoms (fever, tachycardia >100, tachypnea>24)
  • Abnormal physical exam (crackles, decreased breath sounds, bronchial breathing)

Antibiotic Stewardship

  • Compassionate communications
  • Describe infection as viral illness
  • Discuss expected course of illness and cough duration (2-3w)
  • Explain antibiotics do not shorten illness duration, and may cause adverse effects and antibiotic resistance
  • Treatment plan including symptom management (analgesia, antiinflammatory)
  • Consider
    • Delayed prescription strategies (agree on time frame, eg. 1 week that symptoms should improve - and only to use prescription after the specified time)
    • Immediate prescribing if suspect pneumonia or high-risk (immunosuppressed)