Upper Respiratory Infection (URI)

Lisa M. Schroeder, MD and Pascale Ferdinand, MD, MPH Reviewed 06/2017
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Subject: Upper Respiratory Infection (URI)

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BASICS

Upper respiratory infections (URIs) are one of the most common medical diagnoses, contributing to ~30 million office visits annually and resulting in significant lost productivity through missed days from work/school. 

DESCRIPTION

  • Inflammation of nasal passages resulting from infection with respiratory viruses

  • Most cases are mild to moderate in severity, self-limited, and amenable to self-treat.

  • System(s) affected: ENT; pulmonary

EPIDEMIOLOGY

  • Each virus has different seasonal peaks (e.g., rhinovirus: late spring, fall); most infections occur during the winter months.

  • Symptoms usually peak in 1 to 3 days and can last up to 2 weeks.

  • Transmission:

    • Contact with contaminated skin/surface followed by contact with mucous membranes (hand-to-face contact)

    • Aerosolized particles from sneezing and coughing

  • Viruses may last up to 2 hours on skin and even longer on environmental surfaces.

INCIDENCE

  • Predominant age: children > adults

    • Preschool children: 5 to 7 URI/year

    • Kindergarten: 12 URI/year

    • Schoolchildren: 7 URI/year

    • Adolescents/adults: 2 to 3 URI/year

  • Predominant sex: male = female

ETIOLOGY

Rhinoviruses infect the ciliated epithelial mucosa of the upper airway, resulting in edema, hyperemia, and mucous production. 
  • Histology: edema of subepithelial connective tissue and a scanty cellular infiltrate containing neutrophils, plasma cells, lymphocytes, and eosinophils with exudation of serous and mucinous fluid

  • Rhinovirus causes a “nondestructive” inflammation of the mucous membranes.

  • Influenza and parainfluenza viruses denude respiratory epithelium to the basement membrane.

  • Several hundred viral strains from different families; spread within geographic region and groups with close contact

    • Rhinovirus (>100 serotypes): 30–50%; incubation period 1 to 5 days

    • Influenza virus types A, B, C: 10–15%; incubation period 1 to 4 days

    • Coronaviruses: 10–15%

    • Parainfluenza, respiratory syncytial virus (RSV): 5%; more common in children; incubation period 1 week

    • Enteroviruses, adenoviruses: <10%

  • In many cases, no specific pathogen is identified.

RISK FACTORS

  • Exposure to infected people

  • Touching one’s face with contaminated fingers

  • Allergic disorders

  • Smoking

  • Immunosuppression

  • Stress

GENERAL PREVENTION

  • Frequent hand washing, especially in children

  • Limiting exposure to infected persons/children

ASSOCIATED CONDITIONS

  • Pharyngitis

  • Sinusitis

  • Otitis media

  • Bronchitis

  • Bronchiolitis

  • Pneumonia

  • Croup

  • Asthma

DIAGNOSIS

HISTORY

  • Nasal congestion: 80–100%

  • Sneezing: 50–70%

  • Throat irritation: 50%

  • Cough: 40%

  • Hoarseness: 30%

  • Malaise: 20–25%

  • Headache: 25%

  • Fever >100°F (37.7°C): 0–1%

PHYSICAL EXAM

  • Low-grade temperature; mild tachycardia common with fever; tachypnea if significant respiratory involvement

  • Rhinorrhea (clear, yellow, or green)

  • Mucosal edema and/or inflammation

  • Postnasal drainage

  • Pharyngeal erythema

  • Dull tympanic membranes

DIFFERENTIAL DIAGNOSIS

  • Allergic rhinitis

  • Acute sinusitis

  • Strep pharyngitis

  • Epiglottitis

  • Pneumonia

  • Influenza

  • Infectious mononucleosis

  • Pertussis

  • Otitis media

TESTS

INITIAL TESTS

  • No routine lab testing is typically needed, as diagnosis is based on clinical findings.

  • In cases of pharyngitis, rapid streptococcal antigen testing with reflex culture can be used to rule out group A streptococcal infection if clinically suspected.

  • Rapid influenza antigen testing if influenza is suspected.

  • Heterophile antibody testing if infectious mononucleosis is suspected.

  • Imaging not routinely indicated

TESTS CONSIDERATIONS
  • Patients should consider contacting a physician’s office for fever >101°F associated with systemic symptoms, difficulty breathing, or purulent drainage >2 days.

  • Use of procalcitonin as a guide for directing antibiotic therapy has been increasing in the outpatient and inpatient settings. It has been associated with reduced antibiotic consumption and may help in differentiating between acute viral URI and other bacterial respiratory infections (1).

TREATMENT

GENERAL MEASURES

  • Smoking cessation

  • Vaporizer/humidifier: no consistent benefit proven

  • Cold preparations do not change course

  • Antibiotics not indicated

  • Avoid cough and cold preparations in children under 2 years of age.

MEDICATION

Most cases of URI resolve spontaneously without specific intervention. Treatment is symptom-driven. 

FIRST LINE

  • Saline nasal irrigation is safe for adults and children.

  • Antibiotics are not recommended. They produce minimal to no reduction in symptoms or duration, with greater risk of side effects from usage (2)[A].

  • Analgesics: acetaminophen, and NSAIDs for relieving aches and pains associated with URI

  • Zinc Acetate lozenges every 3 hours started in first 24 hours of illness may shorten course of illness by over 24 hours

SECOND LINE

  • Many mouthwashes, gargles, and lozenges are promoted to relieve the pain of sore throat. The demulcent effects of hard candy, gargling with warm saline, and products with anesthetics (benzocaine/phenol) may provide pain relief.

  • Aromatic oils (menthol, camphor, eucalyptus), produce a sensation of increased airflow without a significant change in airflow resistance.

  • Topical decongestants (sympathomimetics) reduce nasal mucosa swelling and airflow resistance, promote drainage. Sprays preferred over drops in patients >6 years of age:

    • Limit use to 3 days, as rebound congestion may occur after 72 hours of use with resultant rhinitis medicamentosa.

      • Oxymetazoline

        • Adults and children aged 6 to 12 years: 0.05% solution, 2 to 3 sprays in each nostril BID

  • Oral decongestants (sympathomimetic) have some advantages over topical decongestants: longer duration of action, lack of local irritation, and no risk of rebound congestion.

    • Pseudoephedrine: potential for abuse/misuse or diversion for methamphetamine production

    • Use with caution for patients with cardiovascular disease, HTN, and BPH:

      • Adults: 60 mg q4–6h (120 mg sustained-release q12h) superior to placebo in short-term use

      • Children aged 6 to 12 years: 30 mg q4 to 6h; 2 to 5 years: 15 mg q4 to 6h

  • Acute cough, postnasal drip, and throat clearing associated with the common cold can be treated with a 1st-generation antihistamine/decongestant preparation (brompheniramine and sustained-release pseudoephedrine).

  • Antihistamines: minimal benefit when used as monotherapy. Only 1st-generation (sedating) antihistamines show any symptomatic relief, but sedation may be worse than relief:

    • Chlorpheniramine

      • Adults: 4 mg QID, 8 mg TID, 12 mg BID

      • Children age 6 to 12 years: 2 mg q4–6h

      • Children age 2 to 5 years: 1 mg q4–6h

    • Diphenhydramine

      • Adults: 25 to 50 mg q4–6h PRN

      • Children age 6 to 12 years 12.5 to 25 mg q4–6h PRN

      • Children age 2 to 6 years: 6.25 mg q4–6h PRN

Pediatric Considerations

In 2007, the FDA issued a warning to limit use of all cough/cold preparations for children age ≤2 years (3)[A].

 

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Zinc prevents viral replication in vitro:

    • Avoid intranasal preparations of zinc: risk of potential permanent loss of smell (4)

    • Has shown moderate benefit in reducing symptoms and duration, but proper dosing has not been determined

    • Best if taken with 24 hours of onset of symptoms

  • Echinacea has not proven consistently effective for treatment of common cold symptoms (5)[C].

  • Probiotics may decrease severity and duration of URIs and possibly reduce episodes (6)[B].

  • Vitamin C (ascorbic acid) (7)[C]

    • Regular supplementation trials have shown that vitamin C may reduce the duration of colds.

    • Vitamin C prophylaxis not recommended for general use but may be beneficial in those exposed to severe physical exertion and cold environments.

Geriatric Considerations

Cold medications, especially decongestants and antihistamines, commonly produce adverse effects in older patients and should not be used routinely.

 
Pregnancy Considerations

  • Decongestants: Most are Category B or C.

  • Antihistamines: Most are Category B or C.

 

ONGOING CARE

FOLLOWUP RECOMMENDATIONS

Contact a physician’s office for prolonged fever, difficulty breathing, or concern for secondary complications. 

DIET

Encourage fluids and adequate hydration. 

PATIENT TEACHING

  • Discuss the difference between viral and bacterial infections; instruct about appropriate antibiotic use.

  • Good hand hygiene

  • Symptomatic treatment; no cure

  • Reinfection is possible with reexposure.

  • Patient information: www.niaid.nih.gov/factsheets/cold.htm

PROGNOSIS

  • Excellent; expect full recovery. Usual duration 5 to 7 days but may last up to 2 weeks; for smokers, 3 to 4 additional days

  • Cough may persist after other symptoms have resolved.

COMPLICATIONS

Small percentage may develop worsening symptoms leading to secondary otitis media, sinusitis, bronchitis, or pneumonia. 

REFERENCES

Schuetz P, Müller B, Christ-Crain M et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev.  2012;(9):CD007498.  [View Abstract]
Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev.  2013;(6):CD000247.  [View Abstract]
Centers for Disease Control and Prevention. Infant deaths associated with cough and cold medications—two states, 2005. MMWR Morb Mortal Wkly Rep.  2007;56(1):1–4.  [View Abstract]
Hemilä H, Chalker E. The effectiveness of high dose zinc acetate lozenges on various common cold symptoms: a meta-analysis. BMC Family Practice.  2015;16:24.  [View Abstract]
Linde K, Barrett B, Wölkart K et al. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev.  2006;(1):CD000530.  [View Abstract]
Hao Q, Lu Z, Dong BR et al. Probiotics for preventing acute upper respiratory tract infections. Cochrane Database Syst Rev.  2011;(9):CD006895.  [View Abstract]
Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev.  2013;(1):CD000980.  [View Abstract]

ADDITIONAL READING

Wald ER, Applegate KE, Bordley C et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics.  2013;132(1):e262–e280.  [View Abstract] 

SEE ALSO

Bronchitis, Acute; Pharyngitis; Rhinitis, Allergic 

CODES

ICD10

  • J06.9 Acute upper respiratory infection, unspecified

  • J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations

  • B97.4 Respiratory syncytial virus causing diseases classd elswhr

ICD9

  • 465.9 Acute upper respiratory infections of unspecified site

  • 465.8 Acute upper respiratory infections of other multiple sites

  • 487.1 Influenza with other respiratory manifestations

  • 079.6 Respiratory syncytial virus (RSV)

SNOMED

  • 54150009 upper respiratory infection (disorder)

  • 43692000 Influenzal acute upper respiratory infection

  • 281794004 Viral upper respiratory tract infection (disorder)

  • 55735004 Respiratory syncytial virus infection (disorder)

PEARLS

  • Supportive therapy is mainstay for most upper respiratory tract infections.

  • Point of care testing can rule out group A Streptococcus infection in the appropriate clinical setting.

  • Limit unnecessary use of antibiotics.

  • URI symptoms last 3 to 4 days longer in smokers.

 
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