A variety of viruses and bacteria can cause upper respiratory tract infections. These cause a variety of patient diseases including acute bronchitis, the common cold, influenza, and respiratory distress syndromes. Defining most of these patient diseases is difficult because the presentations connected with upper respiratory tract infections (URIs) commonly overlap and their causes are similar. Upper respiratory tract infections can be defined as self-limited irritation and swelling of the upper airways with associated cough with no proof of pneumonia, lacking a separate condition to account for the patient symptoms, or with no history of COPD/emphysema/chronic bronchitis. Upper respiratory tract infections involve the nose, sinuses, pharynx, larynx, and the large airways.

1. UPPER RESPIRATORY
TRACT INFECTION

2. Introduction
A variety of viruses and bacteria can cause upper respiratory tract infections. These
cause a variety of patient diseases including acute bronchitis, the common cold,
influenza, and respiratory distress syndromes. Defining most of these patient
diseases is difficult because the presentations connected with upper respiratory tract
infections (URIs) commonly overlap and their causes are similar. Upper
respiratory tract infections can be defined as self-limited irritation and swelling
of the upper airways with associated cough with no proof of pneumonia,
lacking a separate condition to account for the patient symptoms, or with no
history of COPD/emphysema/chronic bronchitis. Upper respiratory tract
infections involve the nose, sinuses, pharynx, larynx, and the large airways.

3. Etiology
Common cold continues to be a large burden on society,
economically and socially. The most common virus is rhinovirus.
Other viruses include the influenza virus, adenovirus,
enterovirus, and respiratory syncytial virus. Bacteria may cause
roughly 15% of sudden onset pharyngitis presentations. The most
common is Streptococcus pyogenes, a Group A streptococcus.

4. Risk factors for a URTI
Close contact with children: both daycares and schools increase the risk
for URI
Medical disorder: People with asthma and allergic rhinitis are more likely
to develop URI
Smoking is a common risk factor for URI
Immunocompromised individuals including those with cystic fibrosis, HIV,
use of corticosteroids, transplantation, and post-splenectomy are at high
risk for URI
Anatomical anomalies including facial dysmorphic changes or nasal
polyposis also increase the risk of URI

5. Epidemiology
Across the country, URIs are one of the top three diagnoses in the outpatient setting.
Estimated annual costs for viral URI, not related to influenza, exceeds $22 billion. Upper
respiratory tract infections account for an estimated 10 million outpatient appointments a
year. Relief of symptoms is the main reason for outpatient visits amongst adults during the
initial couple weeks of sickness, and a majority of these appointments result with
physicians needless writing of antibiotic prescriptions. Adults obtain a common cold
around two to three times yearly whereas pediatrics can have up to eight cases yearly. Fall
months see a peak in incidence of common cold caused by the rhinovirus. Upper
respiratory tract infections are accountable for greater than 20 million missed days of
school and greater than 20 million days of work lost, thus generating a large economic
burden.

6. Pathophysiology
A URTI usually involves direct invasion of the upper airway mucosa by the
organism. The organism is usually acquired by inhalation of infected
droplets. Barriers that prevent the organism from attaching to the mucosa
include 1) the hair lining that traps pathogens, 2) the mucus which also
traps organisms 3) the angle between the pharynx and nose which prevents
particles from falling into the airways and 4) ciliated cells in the lower
airways that transport the pathogens back to the pharynx.
The adenoids and tonsils also contain immunological cells that attack the
pathogens.

7. Influenza
The incubation period for influenza is 1 to 4 days, and the time interval between
symptom onset is estimated to be 3 to 4 days. Viral shedding can occur 1 day
before the onset of symptoms. It is believed that influenza can be transferred
among humans by direct contact, indirect contact, droplets, or aerosolization.
Short distances (<1 meter) are generally required for contact and droplet
transmission to occur between the source person and the susceptible individual.
Airborne transmission may occur over longer distances (>1 m). Most evidence-
based data suggest that direct contact and droplet transfer are the predominant
modes of transmission for influenza.

8. Common Cold
The pathogens are responsible for causing the common cold include rhinovirus,
adenovirus, parainfluenza virus, respiratory syncytial virus, enterovirus, and
coronavirus. The rhinovirus, a species of the Enterovirus genus of the Picornaviridae
family, is the most common cause of the common cold and causes up to 80% of all
respiratory infections during peak seasons. Dozens of rhinovirus serotypes and
frequent antigenic changes among them make identification, characterization, and
eradication complex. After deposition in the anterior nasal mucosa, rhinovirus
replication and infection are thought to begin upon mucociliary transport to the
posterior nasopharynx and adenoids.

9. As soon as 10 to 12 hours after inoculation, symptoms may begin. The
mean duration of symptoms is 7 to 10 days, but symptoms can persist for as
long as 3 weeks. Nasal mucosal infection and the host's subsequent
inflammatory response cause vasodilation and increased vascular
permeability. These events result in nasal obstruction and rhinorrhea
whereas cholinergic stimulation prompts mucus production and sneezing.

10. History
Acute upper respiratory tract infections include rhinitis, pharyngitis, tonsillitis, and
laryngitis. Symptoms of URTIs commonly include:
•Cough
•Sore throat
•Runny nose
•Nasal congestion
•Headache
•Low-grade fever
•Facial pressure, Sneezing, Malaise , and Myalgias
The onset of symptoms usually begins one to three days after exposure and lasts 7–10
days, and can persist up to 3 weeks.

11. Evaluation
The presence of classical features for rhinovirus infection, coupled with the absence of
signs of bacterial infection or serious respiratory illness, is sufficient to make the
diagnosis of the common cold. The common cold is a clinical diagnosis, and diagnostic
testing is not necessary. When testing for influenza, obtain specimens as close to
symptom onset as possible. Nasal aspirates and swabs are the best specimens to obtain
when testing infants and young children. For older children and adults, swabs and
aspirates from the nasopharynx are preferred. Rapid strep swabs can be used to rule out
bacterial pharyngitis, which could help decrease number of antibiotics being prescribed
for these infections.

12. Treatment / Management
The goal of treatment for the common cold is symptom relief. Decongestants
and combination antihistamine/decongestant medications can limit cough,
congestion, and other symptoms in adults. Avoid cough preparations in
children.H1-receptor antagonists may offer a modest reduction of rhinorrhea
and sneezing during the first 2 days of a cold in adults. First-generation
antihistamines are sedating, so advise the patient about caution during their
use. Topical and oral nasal decongestants (i.e., topical oxymetazoline, oral
pseudoephedrine) have moderate benefit in adults and adolescents in
reducing nasal airway resistance.

13. Evidence-based data does not support the use of antibiotics in the treatment of the
common cold because they do not improve symptoms or shorten the course of
illness. There is also a lack of convincing evidence supporting the use of
dextromethorphan for acute cough.
vitamin C used as daily prophylaxis had a "modest but consistent effect" on the
duration and severity of common cold symptoms (8% and 13% decreases in duration
for adults and children, respectively). When taken therapeutically after the onset of
symptoms, however, high-dose vitamin C has not shown clear benefit in trials.
Early antiviral treatment for influenza infection shortens the duration of influenza
symptoms, decreases the length of hospital stays, and reduces the risk of complications.

14. Recommendations for the treatment of influenza are updated frequently by the Centers
for Disease Control and Prevention based on epidemiologic data and antiviral
resistance patterns.
Give antiviral therapy for influenza within 48 hours of symptom onset (or earlier), and
do not delay treatment for laboratory confirmation if a rapid test is not available.
Antiviral treatment can provide benefit even after 48 hours in pregnant and other high-
risk patients.
Vaccination is the most effective method of preventing influenza illness. Antiviral
chemoprophylaxis is also helpful in preventing influenza (70% to 90% effective) and
should be considered as an adjunct to vaccination in certain scenarios or when
vaccination is unavailable or not possible.

15. Generally, antiviral chemoprophylaxis is used during periods of influenza activity for (1)
high-risk persons who cannot receive vaccination (due to contraindications) or in whom
recent vaccination does not, or is not expected to, afford a sufficient immune response; (2)
controlling outbreaks among high-risk persons in institutional settings; and (3) high-risk
persons with influenza exposures.
Prognosis
URI are common during the winter season and for the most part, are benign, but they can
seriously affect the quality of life for a few weeks. A few individuals may develop
pneumonia, meningitis, sepsis, and bronchitis. Each year, there are isolated cases of death
reported from a URI. Time off work and school is very common. In addition, patients
spend billions of dollars on worthless remedies.

16. There is little evidence that any treatment actually shortens the duration of a viral
URI. Even the vaccine only works in 40-60% of individuals, at best.
Complications
Complications of upper respiratory tract infections are relatively rare, except
with influenza. Complications of influenza infection include primary influenza
viral pneumonia; secondary bacterial pneumonia; sinusitis; otitis media;
coinfection with bacterial agents; and exacerbation of preexisting medical
conditions, particularly asthma and chronic obstructive pulmonary disease.
Pneumonia is one of the most common complications of influenza illness in
children and contributes significantly to morbidity and mortality.

17. Enhancing Healthcare Team Outcomes
Upper respiratory tract infections are one of the most common illnesses that
healthcare workers will encounter in an outpatient setting. The infection may vary
from the common cold to a life-threatening illness like acute epiglottitis. Because of
the diverse causes and presentation, upper respiratory tract infections are best
managed by an interprofessional team.
The key is to avoid over-prescribing of antibiotics but at the same time not missing a
life-threatening infection. Nurse practitioners who see these patients should freely
communicate with an infectious disease expert if there is any doubt about the
severity of the infection. The pharmacist should educate the patient on URI and to
refrain from overusing unproven products.

18. Similarly, the emergency department physician should not readily discharge
patients home with antibiotics for the common cold. Overall, upper respiratory
tract infections lead to very high disability for short periods. Absenteeism from
work and schools is common; in addition, the symptoms can be annoying and
extreme fatigue is the norm. Patients should be encouraged to drink ample fluids,
rest, discontinue smoking and remain compliant with the prescribed medications.
Nursing can monitor the patient's condition and symptoms, counsel on
medication compliance, and report any concerns to the clinicians managing the
case. Finally, clinicians should urge patients to get vaccinated before the flu
season. While the vaccine may not decrease the duration of the infection, the
symptoms are much less severe.

19. THANK YOU