Download The Management of upper respiratory tract infections

J Royal Naval Medical Service 2013, Vol 99.3
97
Clinical
The management of upper respiratory tract infections
R Rennie, B Crowson
Abstract
Upper respiratory tract infections (URTIs), generally termed colds, sore throats and coughs, are common presentations in
primary care. This article discusses the clinical picture, management, significant differential diagnosis, and specifically, when
antibiotics may be required for an URTI.
Introduction
URTIs are very common, with a quarter of the population
presenting to their family doctor with acute respiratory
symptoms each year (1). URTI is used as an umbrella
term for illnesses that are often minor, predominantly
viral in aetiology, and affect the upper airways. The upper
respiratory tract extends from the tympanic membranes to
the tracheal carina: however, the upper bronchi are often
infected by the same viruses and bronchitis may be included
among the spectrum of presentations.
Diagnoses of URTIs include the common cold,
sore throats and simple coughs: however, many others
will also be included, attributable to the multitude of
anatomical structures that may be infected. Patients may
present with any number of focal symptoms, together
with constitutional upset due to otitis media, sinusitis,
pharyngitis, tonsillitis, rhinitis, epiglottitis, laryngitis and
even laryngotracheobronchitis. As the anatomical area is so
varied, the symptoms seen in URTIs are legion (Table 1).
With such a myriad of possible symptoms and potential
diagnoses, differentiation may appear difficult: however, in
practice there is often considerable overlap of symptoms
due to combined infections. This article will look at the clinical
picture, management and the significant differential diagnosis
of the three commonest presenting complaints, namely:
Sore throat
Facial pain
Irritability
Cough
Fever
Ear pain
Shortness
of breath
Headache
Hearing loss
Sneezing
Malaise
Anosmia
Rhinorrhoea
Myalgia
And many more…
Nasal congestion
Fatigue
Table 1: Common symptoms of an URTI
• Common colds
• Sore throats
• Coughs
The primary population of concern here is that of the
healthy young adults that make up the vast majority of UK
armed forces personnel. However, several conditions rarely
seen in this population are also mentioned, such as those
seen in the unvaccinated and in children. These groups may
be encountered when serving overseas or when treating
service family members, so it is important to be aware of
such conditions.
A common and important question discussed is when
antibiotics may be required. General Practitioners (GPs)
constantly strive to promote good antimicrobial stewardship,
reduce unnecessary antibiotic prescribing and limit the risk
of antibiotic resistance development. Antibiotic-resistant
infections lead to additional treatment, investigations, more
expensive medications and longer hospital stays resulting in
an estimated added cost to healthcare services of $55 billion
worldwide. However this is likely to be an underestimate
when one considers how and where antibiotics are utilised
(1). It is therefore important to understand when and which
antibiotics to prescribe, and to only prescribe antibiotics
where necessary. The article will also discuss methods to
reduce antibiotic prescribing.
A summary of the conditions discussed, including the
need for antibiotics, recommended management and usual
natural history is shown in Table 2.
The common cold (coryza)
Clinical picture
Numerous viruses cause colds or coryza, most commonly
rhinoviruses (30-50%), with coronaviruses, adenoviruses
and influenza viruses attributable to the majority of others
(3). Influenza infections are discussed below. No pathogen
is isolated in 20-30% of colds and a small proportion are
98Clinical
Need for antibiotics
Recommended management
Usual natural
history
Common cold
• Rhinorrhoea • Sneezing
• Mild fever • Headache
• Fatigue
Nil
No evidence for vitamins or antihistamines.
One dose of decongestant.
Vapour rub / steam inhalation (as long as care is
taken). Paracetamol / ibuprofen.
Gentle rest but no need for time off work if able.
1.5 weeks
Sinusitis
• Congestion • Facial pain
• Rhinorrhoea
If purulent nasal discharge for
>7days – 7 days of amoxicillin /
clarithromycin
Analgesia –
Paracetamol / ibuprofen.
2.5 weeks
Otitis Media
• Ear pain • Hearing loss
• Ear discharge
If persistent discharge or if <2
years of age – 5 days of amoxicillin
/ clarithromycin
Analgesia –
Paracetamol / ibuprofen.
4 days
Influenza
• Malaise • Fever
• Headache • Sore throat
• Cough
Nil
Symptomatic management.
Consider antiviral medication and specialist
input for those at high risk.
1-2 weeks,
usually shorter in
children
Condition and symptoms
HIV
• Coryzal symptoms
• Sore throat • Cough
• Fever
• Maculopapular rash
• Lymphadenopathy
Nil
Pharyngitis/ tonsillitis
• Sore throat
• Pain on swallowing
• Fever
If 3-4 Centor criteria are
met consider 10 days
phenoxymethylpenicillin (penicillin
V) / clarithromycin.
Lower threshold for antibiotics
if 5-15 years old, severe
inflammation of throat, elderly or
immunocompromised
Analgesia –
Paracetamol / ibuprofen.
Could also try benzydamine spray, salt water /
aspirin gargles.
1 week
Nil
Analgesia –
Paracetamol / ibuprofen.
Gargles not helpful.
Rest voice. Humidified air may help.
7-10 days
Scarlet Fever
• Sore throat • Erythematous,
sandpapery rash
• Circumoral pallor
• “Strawberry” tongue
• Peeling skin
10 days phenoxymethylpenicillin
(penicillin V) / clarithromycin
Analgesia and symptomatic treatment.
If no access to antibiotics patients may be at
risk of developing rheumatic fever.
1 week for the
initial illness.
3 weeks
afterwards skin
peeling may occur
Quinsy
• Fever • Sore throat
• Deviated uvula
• Tonsillar abscess - swelling
of the soft palate
IV antibiotics may be indicated
Quinsy will likely need to be drained and
reviewed in secondary care.
This can vary
depending on
the extent of the
infection
Laryngitis
• Hoarse voice • Vocal loss
• Sore throat • Cough
Glandular fever
• Malaise / fatigue • Fever
• Lymphadenopathy
• Sore throat
• Petechiae on the palate
• Swollen spleen
Cough / Bronchitis
• Cough • Sore throat
• Other features of an URTI
Nil
Especially avoid amoxicillin
Nil unless signs of LRTI or unless
persists over 3 weeks, then
antibiotics may be considered
depending on features
Table 2: Summary of URTI conditions
Important to consider HIV, ask about risk
factors and test for it.
Refer to GUM clinic if positive.
Symptomatic treatment.
Rest.
No contact sports for one month.
No evidence of over the counter medications
helping at all.
Symptomatic as above.
Seroconversion
illness 2-3
weeks
HIV infection
lifelong
2-4 weeks.
(Fatigue may last
longer)
3 weeks
J Royal Naval Medical Service 2013, Vol 99.3
due to multiple viruses (4). The most common symptoms
include rhinorrhoea, sneezing, coughing, a sore throat,
nasal congestion, and any combination of these (Table 1).
Associated fevers are generally low grade (< 38°C). Colds
are commonly short-lived, lasting on average 7-10 days.
Management
The management of colds is primarily supportive with
treatment aimed at the most prominent symptoms.
Antibiotics should not be prescribed for viral infections as
they will not improve symptoms, nor shorten their duration.
General advice includes ensuring adequate fluid intake,
nutrition and rest and, although there is limited evidence
for this, it is common sense. Vitamin supplements and
antihistamines are of no benefit (5). Absence from work
or school is unnecessary in the majority of cases. In terms
of medication, simple analgesics such as paracetamol and
ibuprofen are the mainstay of treatment. To treat congestion
there may be some benefit from using vapour rubs, especially
in children, as well as steam inhalation. There is some
controversy over advising steam inhalation due to concerns
over patient safety following case reports of severe scalds.
Patients should therefore be cautioned of the risks or advised
to use a shower as a safer environment to inhale steam. Oral
decongestants, such as pseudoephedrine, have been shown
to be beneficial after a single dose but studies show little
benefit thereafter (6). Patients should be warned, however,
that when taking over-the-counter (OTC) decongestants
side effects may include insomnia and rebound congestion
on cessation. They should be avoided in patients with
diabetes, hypertension, hyperthyroidism, glaucoma, prostatic
hypertrophy and ischaemic heart disease, and in those taking
anti-hypertensives and certain antidepressants (7).
Differential diagnosis and complications
Sinusitis (inflammation of the mucosal lining of the paranasal
sinuses) is characterised by facial pain, nasal congestion,
copious nasal discharge, which is occasionally purulent
(indicating a bacterial infection), anosmia and fever. It is one
of the commonest reasons for GPs to prescribe antibiotics:
however, only approximately one-third of infections will
have a bacterial component, typically due to Streptococcus
pneumonia, or occasionally Haemophilus influenzae or
Moraxella catarrhalis (8,9). It also tends to persist longer
than a cold, lasting approximately 2-3 weeks. Meta-analyses
of the evidence show that antibiotics can provide some, but
minimal, improvement; the numbers needed to treat for one
patient to benefit are 18. Unfortunately, side effects associated
with antibiotics use include rash, abdominal pain, diarrhoea,
nausea or vomiting and the numbers needed to harm are
only 8.1, suggesting that after giving 18 patients antibiotics
only one will gain a small amount of relief and at least two
will experience significant side effects (10,11). This evidence
highlights the need to consider antimicrobial prescribing
carefully, evaluating both risks and benefits. Features that
may increase the likely need for antibiotics are purulent nasal
99
discharge of over 7 days’ duration. Should antibiotics be
prescribed the current guidelines are for 7 days of amoxicillin
or, for those with penicillin allergy, clarithromycin (7).
Otitis media is an infection of the middle ear that often
accompanies coryzal symptoms. Again, it is often viral but
occasionally bacterial (due to similar pathogens causing
sinusitis) and occurs more commonly in children than
adults. Very young children will often pull or rub their ear.
Older children and adults will describe unilateral earache
and occasionally a degree of hearing loss. Some may also
develop an effusion which can lead to a tympanic membrane
perforation resulting in a purulent discharge from the ear.
This typically relieves the symptoms of pain, but advice
regarding keeping the ear dry is essential to avoid recurrent
infections and potential scarring before the membrane
heals. Such discharge often influences decisions to prescribe
antibiotics. Otitis media typically lasts 4-5 days and therefore
patients (or the parents of a patient) may be encouraged to
wait. It is recommended that antibiotics are prescribed if
discharge is present or if the patient is less than 2 years old
with bilateral symptoms or bulging tympanic membranes
(12). Current guidelines are for 5 days of amoxicillin or, for
those with penicillin allergy, clarithromycin (7).
Influenza
Seasonal influenza infection is a common and an important
differential diagnosis to consider, particularly in those
who are under 5 years old, the elderly, pregnant women,
or those with co-morbidities, as they are at higher risk of
significant complications such as pneumonia, heart failure
and encephalitis. Patients with influenza typically experience
a systemic illness and complain of headache, loss of appetite,
fatigue, malaise and myalgia, which are more prominent
than in a simple coryzal illness.
Influenza viruses comprise three serotypes (A, B and
C) and are further described by the surface antigens, H
(haemagglutinin) and N (neuraminidase). A and B viruses
tend to be more common, with the former responsible for the
majority of pandemics such as the recent A–H1N1 strain that
led to significant UK mortality of >400 deaths in 2009-2011
(13). The viruses exhibit pronounced antigenic variation
between seasonal outbreaks. The UK’s annual influenza
vaccination program employs vaccines against multiple
common strains that are currently deemed significant. This
year’s vaccine will include A–H1N1, as well as strains of
an A–H3N2 and an influenza B strain (14). A nasal spray
vaccine will also be provided for children aged 2-3 years and
will be subsequently extended to include all children aged
2-16 years. In March 2013 a new avian influenza strain was
identified as the cause of influenza in humans in China.
This was a new A–H7N9 strain that has so far infected 135
people and caused 45 deaths, a mortality rate of ~32%. At
present there has been little human-to-human transmission
reported and there have been no new infections reported
since August 2013 (15). Management is often supportive
and includes simple analgesia and good hydration. However,
100Clinical
antiviral medication, such as oseltamivir or zanamivir, is
advised if the patient is in a high risk group and can start the
treatment within 36-48 hours of the onset of symptoms (16).
These patients should be monitored closely as specialist
care may be required if any complications develop.
Human Immunodeficiency Virus (HIV)
By the end of 2001, an estimated 96,000 people were
living with HIV in the UK with a quarter unaware of their
infection. Due to the advances in the management of HIV
over the past 25 years, a near-normal life expectancy can
now be expected if patients are diagnosed early, provided
with effective antiretroviral therapy, and have no other comorbidities (17). Unfortunately however, the diagnosis
is still not considered routinely and in 2011, 47% of those
diagnosed with HIV were late diagnoses, having adverse
ramifications for life expectancy. Those diagnosed late have
a tenfold increased risk of dying within a year of diagnosis
(18). National mortality data show that 24% of all deaths
and 35% of HIV related deaths in those with HIV are directly
attributable to a late diagnosis (19). It is therefore vital to
consider a diagnosis of HIV and to test for it.
Up to 90% of patients with primary HIV infection (PHI)
will have some sort of seroconversion illness that will often
mimic viral illnesses (20). Patients can present with symptoms
such as fevers, maculopapular rashes, myalgia, pharyngitis,
or headaches. Clinicians need to be alert to PHI in the ‘noncough, non-rhinitis’ viral illness. It is very important to think
about the possibility of HIV during this initial consultation
as patients will improve spontaneously in two to three weeks,
after which they may not return and the chance to diagnose
HIV during their acute infection would have been missed.
PHI is the point during infection that a patient is at highest
infectivity and the risks of onward transmission are much
greater. The other opportunity to test for HIV is in patients
with puzzling clinical pictures, unexplained blood indices or
those with, or when testing for, other sexually transmitted
infections or blood borne viruses. Testing for HIV may well
be expected as routine in a genitourinary medicine (GUM)
clinic: however, consultations within primary care provide
the ideal opportunity to offer testing, particularly for those
who would not otherwise attend a GUM clinic. Lengthy pretest counselling is no longer recommended by the British
HIV Association and the British Association for Sexual
Health and HIV, from whom there has been significant
encouragement to normalise HIV testing in this era of
simple treatment and excellent prognoses. Emphasising the
routine nature of testing as part of a batch of other ‘standard/
routine tests’ is often useful, such as including an HIV test
amongst the rest of the ‘viral’, ‘infection’ screen.
Whilst a sexual history enquiring about risk factors
including men who have sex with men and sexual contact in
higher prevalence countries can be useful in the PHI setting,
many patients may not have participated in any particular
‘high risk’ activities. Rather than spending time performing
a risk assessment and potentially reaching the wrong
conclusion, it is far safer to just do the test; if an HIV test
is reported as positive you have saved a life. It is important
to remember that there is 24-hour mobile and email access
to the Military Advice Service for Sexual Health and HIV for
advice on the next steps and referral of military patients for
specialist review (Table 3).
Sore throats
Clinical picture
If the predominant symptom of an URTI is a sore throat
(pharyngitis) patients will generally complain of pain
on eating and occasionally on drinking, increasing their
susceptibility to dehydration. This should be assessed for,
on a background of high fevers and constitutional upset.
Although rare, especially in adults, significant tonsillar
inflammation and secondary tonsillitis may cause airway
obstruction. Dehydration, breathing difficulties and stridor
should prompt an urgent admission to secondary care.
Progressive infection may lead to inflammation of the
larynx or vocal cords resulting in laryngitis, a hoarse voice and
occasionally vocal loss. This typically lasts for 7-10 days but nonresolving symptoms > 3 weeks, especially in the absence of other
URTI features, should prompt referral for a specialist opinion.
However, the majority of sore throats are due to simple
viral infections and will usually settle within 3-4 days, with
90% resolving within 7 days (21). The commonest bacterial
cause is streptococcus (‘strep throat’), particularly Lancefield
group A beta-haemolytic streptococci (GABHS). However,
other groups such as C and G can also cause similar
symptoms. The greatest difficulty comes when attempting
to distinguish between viral or bacterial infections.
Management
The Centor criteria are the most commonly used clinically
for determining whether a sore throat is bacterial (22).
The four variables considered from the history and clinical
examination are tonsillar exudates, swollen tender anterior
cervical lymph nodes, lack of a cough, and history of fever.
On-call email: [email protected]
On-call mobile: (+44) 7975 953539
Table 3: Contact details for Military Advice Service for Sexual
Health and HIV
Rapid onset of symptoms
Chest pain
Extreme difficulty breathing
Peak flow <33% of expected
Respiratory rate >30/min
Systolic BP <90 mmHg,
Diastolic BP <60 mmHg
Oxygen saturations <92%
Tachycardia >130 bpm
Table 4: Symptoms to indicate an emergency admission
J Royal Naval Medical Service 2013, Vol 99.3
Patients with all these elements have a 56% probability of a
positive culture from a throat swab. First proposed in 1981,
these criteria have since been validated and adopted to
guide antibiotic prescribing. In addition the Centor criteria
are of particular use for patients aged 5-15 years, in whom a
streptococcal infection is a more likely cause. More recently
rapid antigen testing (RAT), used in combination with
the Centor criteria, has been shown to improve sensitivity
and the correct diagnosis of streptococcus (23). This is
commonly used in North America due to the impact on
reducing antibiotic prescribing: however, it is not yet certain
whether there is a cost benefit in the UK. RAT and cultures
from throat swabs are limited to testing surface antigens,
not necessarily the organisms in the tonsillar crypts likely
to be the causative pathogen and it is, therefore, difficult to
distinguish between an infecting organism and the patient’s
normal oral flora (24). Guidelines therefore advocate using
the Centor criteria, but highlight that it is not diagnostic (10,
24). Other factors shown to have a positive predictive value
include whether a patient presents in the first three days of
illness, or even merely the doctor’s subjective opinion from
examining the patient’s throat (25).
The recommended antibiotic for a streptococcal throat
infection is phenoxymethylpenicillin (Penicillin V) for 10
days, shown to result in a lower relapse rate in randomised
controlled trials (26). The total benefit from antibiotics is
usually minimal, only shortening the duration of symptoms
by 16 hours (21). Amoxicillin, ampicillin or co-amoxiclav
should not be given due to the risk of causing a rash if the
underlying diagnosis is glandular fever.
Management of associated pain is also important, often
requiring regular simple analgesia such as paracetamol and/
or ibuprofen. In addition, topical preparations of anaesthetic
medications (benzydamine hydrochloride spray – Difflam),
or antiseptic mouthwashes (chlorhexadine) may provide
some relief (27). While there is little evidence to support
the use of salt-water gargles or gargling with aspirin or
paracetamol, these preparations are anecdotally beneficial
and will do little to harm the patient: however, evidence
suggests that benzydamine is superior at treating throat pain
(28). If laryngitis is a feature, systemic oral analgesia should
be advised. The best advice for a hoarse voice is complete
rest: also, breathing humidified air may help (29).
Differential diagnosis and complications
Complications of note following a streptococcal throat
infection include scarlet fever and, although now rarely seen in
the UK, rheumatic fever. This remains prevalent in resourcepoor countries, and particularly in areas of overcrowding, poor
sanitation or limited access to medical care.
Scarlet fever presents with a blanching erythematous,
sandpaper-like rash around the second day of illness, starting
at the neck and advancing distally. Facial flushing and
circumoral pallor will accompany pharyngitis along with a
bright red or “strawberry” tongue. The initial illness usually
settles within a week: however, several weeks later peeling
101
or desquamation of the skin may occur (30). Penicillin and
supportive treatment are usually required.
Rheumatic fever is one of the most significant
complications from GABHS infection. It is diagnosed
using the Jones criteria comprising major (migratory
polyarthritis, carditis, erythema marginatum, Sydenham’s
chorea, subcutaneous nodules) and minor (arthralgia, fever,
first degree heart block, elevated inflammatory markers
e.g. ESR, CRP) symptoms. These occur 1-5 weeks after a
streptococcal infection and may lead to significant cardiac
complications (rheumatic heart disease is estimated to
cause 233,000 deaths annually worldwide) (31). Bacterial
pharyngitis should therefore be treated with antibiotics.
Quinsy
A peritonsillar abscess, or quinsy, can occur with a bacterial
infection, causing a rapidly progressive systemic illness
in some cases. They are commonest in those aged 21-40
years, typical of the military population at risk, and are more
prevalent in males and smokers (32). A fever (>38°C) and
a very sore throat on the side of the abscess are typical and
patients may complain of ipsilateral ear pain, pain opening
their mouth (trismus) and occasionally a hoarse voice. An
enlarging abscess may cause difficulty and pain swallowing
(odynophagia) and affect breathing. These are signs that the
airway may be compromised, which is a clinical emergency.
On examination, inspection of the throat will reveal a very
obvious abscess. Patients with a quinsy will likely need
admission for intravenous antibiotics and often abscess
drainage or aspiration.
Glandular fever
Epstein-Barr virus (EBV) is a member of the human
herpes virus group and causes glandular fever or infectious
mononucleosis (IM), which is rare in the over-40s. It is
mildly contagious and transmitted by saliva (and therefore
known as the “kissing disease”). It is difficult to distinguish
from a streptococcal throat or tonsillitis, as the most
common features are fever, cervical lymphadenopathy, a
sore throat or possibly enlarged and inflamed tonsils. It is
therefore important to perform an IM screen (or monospot
blood test) to confirm the diagnosis. Other signs and
symptoms may include petechiae on the palate (~ 60% of
patients) together with several days of a preceding illness
characterised by non-specific symptoms such as fatigue,
malaise, loss of appetite and headaches. Another common
feature of glandular fever is splenomegaly and occasionally
hepatomegaly and jaundice, requiring liver function testing.
Patients should not play contact sports for a month after an
acute EBV infection as minor trauma may lead to splenic
rupture (33). A mobilliform rash (a macular papular rash
that affects the trunk and tends to coalesce) will develop
after 7-10 days in some patients following treatment with
amoxicillin, which is almost diagnostic for EBV infection
(34). Another common feature is fatigue after the initial
infection which can persist for over 6 months. To manage
102Clinical
the acute infection, symptomatic care is required: however,
if breathing or swallowing difficulties, severe abdominal pain
or jaundice develop, urgent hospital admission is needed.
Following the acute infection, avoidance of contact sports
and a return to normal activity as soon as possible should be
advised, with the caveat that the fatigue may be prolonged.
Exclusion from school or work is not required.
Cough
Clinical picture
Irritation of the airways can lead to a cough which is usually
non-productive in a mild viral URTI. If the infecting virus
invades the lining of the trachea and upper bronchi, bronchitis
may develop. The cough will often last somewhat longer than
a simple cold due to the slow repair of the lining of the trachea
and bronchi, but it is usually no longer than three weeks (35).
Management
If a patient presents early with a simple cough due to an
URTI, management is supportive, as for colds and sore
throats. Antibiotics are of no benefit in a viral cough or
bronchitis: however, assessment for lower respiratory tract
infection (LRTI) should be made, as antibiotics may be
needed. Any time a patient who smokes presents with a
cough should also be considered a good opportunity to
discuss smoking cessation.
In terms of symptomatic relief there is little evidence
that any OTC cough preparations are of benefit: however,
there is some evidence that simple honey may help (36, 37).
An acute cough (<3 weeks) may be attributed to
many other pulmonary causes, some of which can be
very significant. Symptoms suggestive of severe LRTI or
pneumonia, an acute exacerbation of asthma or chronic
obstructive pulmonary disease (COPD), a pneumothorax
or a pulmonary embolism (PE), should lead to further
assessment and investigation. Patients with symptoms listed
in Table 4 should be seen as an emergency.
Differential diagnosis
A brief summary of the common acute lower respiratory
tract conditions seen is outlined in Summary Table 5.
A chronic cough (>3 weeks), not seemingly due to
a pulmonary aetiology, requires further investigation.
Common causes of a persistent cough include smoking,
side effects of medication, chronic sinusitis with a postnasal drip, gastro-oesophageal reflux disease and, although
very rare in a population as young as members of the armed
forces, lung cancer. Patients should therefore be assessed
for each of these.
Special populations
Although military personnel are typically a healthy adult
population with no significant co-morbidities, it is important
to consider issues pertinent to non-military groups that may
be encountered during deployments.
The unvaccinated population
The UK has a comprehensive vaccination program: however,
despite the global strategy of extended programmes of
immunisation (EPI), many other countries do not benefit
from the consistent delivery of such a programme, often
due to conflict and logistical problems etc. Table 6 shows
the diseases vaccinated against in the UK and summarises
the main presenting features of each. Important features
that may imply a condition other than a common viral
URTI may be the severity of the illness, a very high fever,
lymphadenopathy or rashes. It is important that any
unvaccinated patient with those features be reviewed and
these infections considered. Liaison with allied medical
teams is often crucial to and utilise their extensive expertise
and determine local patterns of disease.
The very young
Children often present to GPs in the first year of life due to
increased susceptibility to URTIs secondary to naïve host
immunity. Bronchiolitis, caused by the respiratory syncytial
Condition
Symptoms
LRTI or Pneumonia
Cough productive of purulent sputum. Fever can be very high.
Pleuritic chest pain. Shortness of breath.
Asthma
Non-productive cough, worse at night.
Shortness of breath or wheeze triggered by exercise, cold, pets, pollen, dust or other allergens.
History of asthma, eczema or allergies. Decreased Peak Flow
COPD
Cough that is non-productive or clear sputum.
Current or ex-smoker. Tight-chested or wheezy.
Pulmonary Embolism
Shortness of breath. Chest pain, worse on breathing.
Tachycardia. Coughing up blood. Signs of a DVT (swollen, tender calf)
Pneumothorax
Sudden onset of pleuritic chest pain. Acute shortness of breath.
Tachycardia. Collapse. No preceding illness.
Summary Table 5: Common lower respiratory tract conditions and their symptoms
J Royal Naval Medical Service 2013, Vol 99.3
virus (RSV), and laryngotracheobronchitis or croup due to
parainfluenza (PIV) are of particular importance.
Bronchiolitis usually presents in babies under 12 months
(typically between 3-6 months) and often in the winter
months. Usually presenting as a mild infection with
coryzal symptoms, RSV may also cause more severe
symptoms including tachypnoea and bronchoconstriction,
and an increased respiratory effort as demonstrated by
nostril flaring and intercostal recession. Feeding may also
deteriorate: any infant with such symptoms should be
admitted for supportive treatment.
Croup is often due to PIV and affects children aged 6
months to 3 years most commonly. Although it may be seen in
older children it is rare in those older than 6 years. Along with
103
characteristic URTI symptoms of rhinorrhea, sore throat and
fever, children also develop a cough that is typically ‘barking’
and quite distinctive. Children are often relatively well but,
with moderate or severe disease, breathing difficulties
resulting in stridor or inspiratory wheeze may develop rapidly,
necessitating hospital admission. The mainstay of treatment
is steroids to reduce the risk of airway obstruction, and
supportive treatment. It can present in a similar fashion to
epiglottitis (Table 6), an infection of the epiglottis secondary
to Haemophilus influenzae B. In epiglottitis, and to a lesser
extent with croup, the stress of the examination and the
examination can increase the risk of airway obstruction and
therefore care should be taken to stay calm throughout the
consultation and not to examine the throat.
Disease
Common symptoms
Diphtheria
Sore throat covered by thick grey exudate or
pseudomembrane. Rhinorrhoea can be blood stained.
Lymphadenopathy. Deep ulcers in the skin can appear on
lower legs, feet and hands.
Tetanus
Few URTI symptoms.
Patient will develop muscle spasms, often starting in the
jaw, 1-2 weeks after infection via a dirty wound
Pertussis
(Whooping cough)
Severe bouts of coughing followed by an inspiratory “whoop”.
Cough can last 2-3 months but antibiotics will shorten duration.
Recent outbreaks have led to vaccination of
pregnant women.
It is most dangerous to the very young so
patients should avoid children.
Polio
A flu-like illness occasionally followed by myalgia, muscle
spasms and possibly meningitis.
Can develop paralysis of muscles, including those used to
speak and swallow.
Rare now due to vaccination but complications can be permanent and very disabling.
Haemophilus
influenzae B
Causes epiglottitis: very sore throat, cough, high fever and
breathing difficulties.
Can also present as pneumonia, meningitis, pericardidits,
arthritis and cellulitis.
Meningococcal disease
(N. meningitidis group C)
Meningitis is a severe disease that presents with fever,
malaise, headache, stiff neck, vomiting and occasionally a
non-blanching rash.
These patients should be given antibiotics
quickly and admitted to hospital.
Measles
URTI symptoms 1-4 days before a rash, stating on the face.
High fever with rash (39-40°C).
Can lead to severe complications such as
pneumonia.
Mumps
URTI symptoms. Low-grade fever.
Swollen, tender parotid gland in cheeks.
Swollen, tender testes in men.
10% of patients can develop meningitis
Rubella
URTI symptoms. Low-grade fever.
Conjunctivitis. Rash starts behind ears.
Occipital lymphadenopathy.
Patients should avoid pregnant women due to
the potential risks to the foetus.
Tuberculosis (TB) (BCG
vaccination)
Weight loss. Fever.
Night sweats. Anorexia. Malaise.
TB has a high prevalence in sub-Saharan
Africa and in parts of Asia: consider TB in patients native to, or who have recently visited,
areas of high prevalence.
Table 6: Diseases vaccinated against in the UK
Important points
It is essential not to examine the throat as this
may cause the airway to obstruct.
Urgent admission to hospital.
104Clinical
Antibiotic prescribing by GPs
The prescribing of antibiotics by GPs has declined over
the last decade: however, research continues to study why
GPs prescribe antibiotics, the aim being to target future
education to effectively reduce prescribing rates further.
Previously, it was thought that GPs prescribed excessively
in order to protect their relationship with patients: however,
qualitative studies do not support this assertion (38). Neither
do all patients who attend with symptoms of an URTI expect
antibiotics - approximately half those who attend state that
they expected antibiotics, and this population is thought to
equate to only 10% of all those with a respiratory infection
(39). Indeed, patients are content to avoid antibiotics as long
as their concerns have been taken seriously, they have been
examined and treatment decisions are explained (40).
Methods for the further reduction of antibiotic
prescribing have been researched, such as offering a delayed
prescription which is delayed either in terms of collecting
and/or when to begin the prescribed antibiotic. The
condition being treated should determine the duration of
the delay, for example, 3 days for otitis media, 5 days for a
sore throat and 10 days for a cough (41). Written information
has also been shown to reduce the number of prescriptions
collected if given with a delayed prescription (42). Advice
on prognosis and likely recovery times may also be helpful.
The durations of the typical natural history of infections are
detailed in Table 2 (12).
a bacterial infection that would benefit from antibiotics.
Patients may expect antibiotics from a consultation, but GPs
tend to overestimate patients’ desire for such treatment. Most
patients are content not to receive antibiotics as long as their
concerns are taken seriously, they are examined and their
symptoms explained. It is therefore important to educate
patients, particularly as to the prognosis of their illness,
occasionally with written information. This may also be an
adjunct to delayed prescriptions which can limit the number
of antibiotics taken and reduce the likelihood of patients
seeking further consultations for the same illness.
Thinking outside the ‘viral URTI’ box is also essential
to diagnose rarer, but significant and occasionally fatal
complications, as early as possible. Often these will be due to
complications of common bacterial infections where courses
of antibiotics will be essential. Risk factors such as age, comorbidities, lack of vaccinations or geographical location must
be determined. A sexual history may also ascertain an increased
risk of HIV: however, this is not essential prior to testing. Early
recognition of an HIV seroconversion illness will be life-saving.
Treating patients with URTIs will continue to account
for a significant part of the workload of GPs and medical
assistants. It is therefore important to know how best to treat
them and provide sensible advice on symptom management.
This will improve wellbeing but rarely reduce the length of
infection. It will also hopefully help patients quickly return to,
or stay at, work and therefore remain operational for longer.
Conclusions
The commonest question for both clinician and patient with
an URTI is often whether antibiotics are needed. It is therefore
important to recognise which symptoms are likely to indicate
Acknowledgements
The authors wish to thank Lt Col NE Dufty RAMC for
editorial advice and contributions.
References
1. Ashworth M, Charlton J, Ballard K et al. Variations in antibiotic
prescribing and consultation rates for acute respiratory infection in UK
general practices 1995-2000. Br J Gen Pract. 2005; 55:603-8.
2. Smith R, Coast J. The true cost of antimicrobial resistance. BMJ. 2013
Mar 11; 346:f1493.
3.
National Institute of Allergy and Infectious Diseases [Internet]. Health
& Research Topics: Common Cold; c2011 [updated 2011 Aug 17].
Available from: http://www.niaid.nih.gov/topics/commoncold [accessed
16 Oct 13]
4. NICE Clinical Knowledge Summary [Internet]. Common cold; c2011
[revised 2011 Nov]. Available from: http://cks.nice.org.uk/commoncold
[accessed 16 Oct 13]
5. Wiest E. Use of nonsedating antihistamines in the common cold. Best
BETS [Internet]. C2011 [updated 2011 Jun 30]. Available from: http://
bestbets.org/bets/bet.php?id=2077 [accessed 16 Oct 13]
6. Eccles R et al. Efficacy and safety of single and multiple doses of
pseudoephedrine in the treatment of nasal congestion associated with
common cold. Am J Rhinology. 2005 Jan-Feb;19(1):25-31
7. Joint Formulary Committee. (2013) British National Formulary. 66th ed.
London: BMJ Group and Pharmaceutical Press.
8. McCormick A, Fleming D, Charlton J. (1995) Morbidity statistics from
general practice. Fourth national study 1991-1992. London: HMSO.
9. NICE Clinical Knowledge Summary [Internet]. Sinusitis; c2011 [revised
2009 Mar]. Available from: http://cks.nice.org.uk/sinusitis [accessed 15
Oct 13]
10.Lemiengre MB, van Driel ML, Merenstein D, Young J, De Sutter AIM.
Antibiotics for clinically diagnosed acute rhinosinusitis in adults.
Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.:
CD006089. DOI: 10.1002/14651858.CD006089.pub4
11.Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams
Jr JW, Mäkelä M. Antibiotics for acute maxillary sinusitis. Cochrane
Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000243.
DOI: 10.1002/14651858.CD000243.pub2
12.National Institute for Health and Clinical Excellence. (2008) NICE
clinical guideline 69: Respiratory tract infections – antibiotic prescribing.
13.Pebody RG, McLean E, Zhao H, Cleary P, Bracebridge S, Foster K,
Charlett A, Hardelid P, Waight P, Ellis J, Bermingham A, Zambon M,
Evans B, Salmon R, McMenamin J, Smyth B, Catchpole M, Watson JM.
Pandemic Influenza A (H1N1) 2009 and mortality in the United
Kingdom: risk factors for death, April 2009 to March 2010. Euro Surveill.
2010; 5(20): pii=19571. Available from: http://www.eurosurveillance.
org/ViewArticle.aspx?ArticleId=19571 [accessed 16 Oct 13]
14.Public Health England and Department of Health. Flu plan – Winter
2013/14. 2013 Jul 26. Available from: https://www.gov.uk/government/
publications/flu-plan-winter-2013-to-2014 [accessed 16 Oct 13]
15. World Health Organization. Influenza at the human-animal interface: J Royal Naval Medical Service 2013, Vol 99.3
105
Summary and assessment as of 7 October 2013. Available from: http://
www.who.int/influenza/human_animal_interface/influenza_h7n9/en/
index.html [accessed 16 Oct 13]
29.Shah RK et al. Acute laryngitis treatment and management. Medscape
[Internet]. C2013 [updated Feb 2013]. Available from: http://www.
emedicine.medscape.com/article/864671-treatment [accessed 16 Oct 13]
16.NICE Clinical Knowledge Summary [Internet]. Influenza - seasonal;
c2011 [revised 2009 Aug]. Available from: http://cks.nice.org.uk/
influenza-seasonal [accessed 16 Oct 13]
30.Kumar P, Clark M, eds. (2005). Clinical medicine. 6th ed. Edinburgh:
Elsevier Saunders.
17. Obel N, Omland LH, Kronburg G et al. Impact of non-HIV and HIV risk
factors on survival in HIV infected patients on HAART: A population based nationwide cohort study. Plos One. 2011; 6 (7);e22698
18.Health Protection Agency. (2012) HIV in the United Kingdom: 2012
Report. Colindale, London: Health Protection Agency.
19.British HIV Association. 2005-6 Full Results of Mortality Audit. 2006.
Available
from:
http://www.bhiva.org/NationalAuditReports.aspx
[accessed 28 Sep 13]
20.Kassutto S, Rosenberg ES. Primary HIV Infection. CID. 2004; 38:14471453.
21.Spinks A, Glasziou PP, Del Mar C. Antibiotics for sore throat. Cochrane
Database of Systematic Reviews 2006, Issue 4. Art. No.: CD000023. DOI:
10.1002/14651858.CD000023.pub3.
22.Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The
diagnosis of strep throat in adults in the emergency room. Med Decis
Making. 1981;1(3):239-46.
23.McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical
validation of guidelines for the management of pharyngitis in children
and adults. JAMA. 2004 Apr 7; 291(13):1587-95.
24.Scottish Intercollegiate Guidelines Network. (2010) SIGN Guidelines
117: Management of sore throat and indications for tonsillectomy.
Edinburgh: SIGN.
25.Little P, Hobbs FDR, Mant D, McNulty CAM, Mullee M. Incidence
and clinical variables associated with streptococcal throat infections: a
prospective diagnostic cohort study. Br J Gen Pract. 2012; 62(604):e787794(8)
26. Schwartz RH, Wientzen RL Jr, Pedreira F, Feroli EJ, Mella GW, Guandolo
VL. Penicillin V for group A streptococcal pharyngotonsillitis.
A randomized trial of seven vs ten days’ therapy. JAMA. 1981 Oct
16;246(16):1790-5.
27.Cingi C et al. Effects of chlorhexadine/benzydamine mouth spray on
pain and quality of life in acute viral pharyngitis: a prospective,
randomized, double-blind, placebo-controlled, multicentre study. Ear
Nose Throat J. 2010 Nov; 89(11):546-9.
28. Argarwal A et al. An evaluation of the efficacy of aspirin and benzydamine
hydrochloride gargle for attenuating postoperative sore throat: a
prospective randomized single-blind study. Anaesthesia and Analgesia.
2006 Oct;103(4):1001-3.
31. Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic
fever and rheumatic heart disease. Clin Epidemiol. 2011; 3:67-84.
32. Dunn N, Lane D, Everitt H, LittleP. Use of antibiotics for sore throat and
incidence of quinsy. Br J Gen Pract. 2007 Jan 1; 57(534):45-49.
33.NICE Clinical Knowledge Summary [Internet]. Glandular Fever; c2011
[revised 2010 Feb]. Available from: http://cks.nice.org.uk/glandular-fever
[accessed 16 Oct 13]
34.DermNet NZ [Internet]. Morbilliform Drug Reaction; c2009 [updated
2013 May 5]. Available from: http://www.dermnetnz.org/reactions/
morbilliform.html [accessed 16 Oct 13]
35.NICE Clinical Knowledge Summary [Internet]. Cough; c2011 [revised
2010 Sep]. Available from: http://cks.nice.org.uk/cough [accessed 16
Oct 13]
36. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications
for acute cough in children and adults in ambulatory settings. Cochrane
Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001831. DOI:
10.1002/14651858.CD001831.pub4
37.Heppermann B. Honey for the symptomatic relief of cough in children
with upper respiratory tract infections. Best BETS [Internet]. c2009
[updated 2009 Apr 15]. Available from: http://bestbets.org/bets/bet.
php?id=1757 [accessed 16 Oct 13]
38.Kumar S, Little P, Britten N. Why do general practitioners prescribe
antibiotics for sore throat? Grounded theory interview study. BMJ. 2003
Jan 18; 326:138
39.McNulty CAM, Nichols T, French DP, Joshi P, Butler CC. Expectations
for consultations and antibiotics for respiratory tract infection in primary
care: the RTI clinical iceberg. Brit J Gen Pract. 2013 Jul;
63(612):e429-e436.
40.van der Velden AW, Pijpers EJ, Kuyvenhoven MM, Tonkin-Crine SKG,
Little P, Verheij TJM. Effectiveness of physician-targeted interventions
to improve antibiotic use for respiratory tract infections. Br J Gen Pract.
2012 Dec; 62(605): e801-807(7).
41.Little P. Delayed prescribing of antibiotics for upper respiratory tract
infection. BMJ. 2005 Aug 4; 331:301.
42.Macfarlane J, Holmes W, Gard P, Thornhill D, Macfarlane R, Hubbard
R. Reducing antibiotic use for acute bronchitis in primary care: blinded,
randomised controlled trial of patient information leaflet Commentary:
More self reliance in patients and fewer antibiotics: still room for
improvement. BMJ. 2002 Jan 12; 324:91.1.
Authors
Surgeon Lieutenant Commander R Rennie RN ST3 GPVT, Roborough Surgery, Plymouth
Surgeon Commander B Crowson RN MRCGP Defence Academy, Shrivenham