QUEST Integration – Viral Upper Respiratory Infection – Treatment for Adults

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Guideline Summary

• This guideline applies to immunocompetent adults without complicating factors.
• Symptoms of VURI usually peak in three to five days and resolve in seven to 14 days.
• Refer to Pharyngitis, Acute – Treatment for Adults for patients with sore throat without rhinorrhea, cough or hoarseness.
• Recognizing signs of serious illness before it becomes life-threatening is a key concern.

Introduction

Upper respiratory tract infections (including the common cold) represent an important target for improving appropriate antibiotic use in ambulatory practice. In 1995, upper respiratory tract infection was the most common reason for seeking ambulatory care in the United States, resulting in more than 37 million visits to physicians' offices and emergency rooms. Antibiotics frequently are prescribed for upper respiratory tract infections.

Goals/Desired Outcomes

The goal of this guideline is to assist patients, through education, to be competent and comfortable with home care of viral upper respiratory infection (VURI), and to improve the appropriateness of care for VURIs while decreasing cost of care. This guideline aims to:

1. Increase the appropriateness of patient visits for VURI
2. Eliminate inappropriate use of antibiotics in patients presenting with cold symptoms.
3. Increase patient knowledge of effective home treatment of cold symptoms.

Diagnosis

Patient will report various combinations of symptoms. The symptoms of VURI may include general malaise, laryngitis, injection of the conjunctivas, decreased appetite, headache and restlessness. Onset of symptoms is rapid. The fever usually lasts one to three days and commonly does not exceed 102° F. Nasal discharge is initially clear and usually becomes yellow or green toward the end of the VURI; this does not signify a bacterial infection and the patient does not need to be seen. The symptoms of a VURI usually peak in three to five days and should resolve in seven to 14 days. A mild cough may persist at night for two to three weeks. Refer to Pharyngitis, Acute – Treatment for Adults for those patients reporting a sore throat without rhinorrhea, cough or hoarseness.

Are symptoms of serious illness present?

Recognizing signs of a serious illness before it becomes life-threatening is usually the medical provider’s key concern. An important purpose of the symptoms information in this subsection is to assist providers and triage personnel in distinguishing between VURI and more serious illness. The urgency index increases with the number and severity of symptoms. Symptoms in the Guideline Summary in this section indicate which patients presenting with VURI symptoms need to be seen by a provider.

Are complicating factors present?

• This guideline applies to patients in normal health and without complicating factors.
• This guideline should be applied with great care, if at all, to any patients with complicating factors.
• Although this guideline would be applied with caution to pregnant women, therapies recommended in this guideline are generally safe for pregnant women except for the use of zinc and dextromethorphan. Dextromethorphan is classified pregnancy category C (no controlled studies; give only if benefits outweigh risks).

Symptoms of serious illness

Upper airway obstruction

Peritonsillar or retropharyngeal abscesses, epiglottitis or related conditions are life-threatening and require combined ENT/anesthesia management in an emergency room or operating room setting.

Lower airway obstruction

Lower airway obstruction signals an underlying or different condition than VURI. If moderate to severe distress is present, this suggests pneumonia, COPD, asthma, foreign body, cardiac condition or other underlying conditions requiring specific evaluation and treatment in an intensive care setting. Such symptoms indicate the need for urgent evaluation, and/or the need for intensive treatment, supplemental oxygen and prolonged observation.

Severe headache

Severe headache could indicate subarachnoid hemorrhage; complications of sinusitis such as cavernous sinus thrombosis or sphenoid sinusitis; meningitis, encephalitis or other conditions. Such symptoms require prompt, intensive evaluation and care.

Treatment summary

• Antibiotics will not shorten or cure VURI
• OTC nasal sprays or decongestants may provide temporary relief of VURI symptoms.
• Cold-related fevers usually are less than 102° F and last <3 days.

Treatment

Antibiotics

• Antibiotics are only effective for treating bacterial infections. Because colds are viral infections, antibiotic use will not cure or shorten their duration. Antibiotics may cause side effects such as gastrointestinal discomfort, diarrhea, allergic reactions and yeast infections.
• Unnecessary use of antibiotics can lead to the development of antibiotic-resistant strains of bacteria.
• Antibiotics may cause side effects such as gastrointestinal discomfort, diarrhea, allergic reactions and yeast infections.

Over-the-counter medications

• Over-the-counter cold and cough medications and acetaminophen do not shorten the duration of VURI.
• For adults with a cold, over-the-counter nasal sprays or decongestants may provide temporary relief of sore throat, runny nose, coughing, minor aches and fever. Because of potential side effects, however, be sure to follow the recommended dosage and precautions. Patients who have high blood pressure, diabetes, thyroid disease, or are pregnant, should check with their physician regarding recommendations for decongestant use.
• Fevers that accompany colds are usually less than 102° F and last fewer than three days. Use medication for discomfort as recommended by a physician.
• In adults, there is some evidence that zinc gluconate may decrease the duration of a cold if started within 24 hours of onset. However, adverse reactions including nausea and bad taste may limit its usefulness. No current studies indicate zinc is effective in treating cold symptoms in children.

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Sources

1. Institute for Clinical Systems Improvement. (2002). Diagnosis and treatment of respiratory illness in children and adults. Copyright 2004, Institute for Clinical Systems Improvement. Used with permission.

References

1. Snow V, Mottur-Pilson C., Gonzales R. (2001). Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults. Ann Intern Med, 134:487-9.

Revision History