Upper Respiratory Tract Infection Summary Page 2015

Christopher Hoffmann MD, Stephen D. Sisson MD/Ambulatory Curriculum

Section 1: Upper respiratory tract infection
Causes: rhinovirus (30-50%); coronavirus (7-18%); influenza (5-7%); RSV (5%); parainfluenza, adenovirus and
enterovirus each <5%
Symptoms: sore throat, sneezing, cough, nasal congestion, headache, sinus pressure, malaise
Complications: rare (<2%), include bacterial sinusitis or otitis media
Treatment: symptomatic; antibiotics are not indicated

Section 2: Influenza
Causes: influenza A; influenza B
o Antigenic drift: small changes in HA and NA antigens
o Antigenic shift: major change in HA or NA antigen; results in pandemic. Swine-origin H1N1 in 2009
represented antigenic shift.
Symptoms: fever, myalgias, malaise/lethargy, non-productive cough, sore throat, delirium
Diagnosis: consider EBV, acute HIV in differential, as clinical overlap significant
Treatment: treatment must begin within 48H of onset of symptoms; vaccination always preferable
o Amantadine/rimantadine: treats only influenza A; resistance widespread
Amantadine: 100mg bid (100mg qd if age>65 or renal insuff)
Rimantadine: 100mg bid (100mg qd if age >65 or renal insuff
o Oseltamivir/zanamivir: treats influenza A and B. Zanamivir is by inhalation; use with caution if h/o reactive
airways.
Oseltamivir: 75mg bid x 5d; Widespread Influenza A H1N1 resistance to this drug seen in 2008-09
season.
Zanamivir: 100mg bid inhalation. Influenza A resistance not seen but use limited by
contraindications (e.g., lung disease, elderly)

Section 3: Pharyngitis
Causes: Same as URTI, but add EBV, HIV, HSV, gonorrhea to differential.
o Major clinical concern is etiology of Streptococcus pyogenes (GABHS)
Complications: major concerns are rheumatic fever and post-streptococcal glomerulonephritis
o Treatment must begin within 9 days of onset of symptoms to prevent these complications
Diagnosis
o Centor criteria
T>38C
Tonsillar exudates
Tender cervical adenopathy
No cough or rhinitis
Treatment (penicillin is antibiotic of choice, with erythromycin used if allergic)
o 0-1 Centor criteria: symptomatic treatment
o 2 or 3 Centor criteria: rapid strep antigen test; antibiotics only if positive
o 4 Centor criteria: empiric antibiotics or rapid strep test and antibiotics if positive

Section 4: Sinusitis
Causes: Same as URTI; major clinical concern is presence of bacterial infection (S. pneumoniae most common; H.
influenzae second most common)
Diagnosis: Features suggestive of acute bacterial sinusitis include fever or any of the following:
o Presence of symptoms>7d or symptoms worsening after initial improvement
o Maxillary tooth pain
o Unilateral facial pain or unilateral sinus tenderness
o Purulent nasal discharge
Treatment: amoxicillin, doxycycline, trimethoprim/sulfamethoxazole are best options; use amoxicillin/clavulanate or
moxi/levofloxacin if recent antibiotic exposure

Section 5: Acute bronchitis
Definition: a respiratory illness of <3wks duration in which cough is primary complaint
Causes: same as URTI, but may include Mycoplasma pneumoniae, Chlamydophila pneumoniae
Diagnosis: differential includes pneumonia or pertussis. American College of Physicians states evaluation should focus
on clinically ruling out pneumonia
Treatment: antibiotics are not indicated for treatment of bronchitis. Beta-agonist inhalers, NSAIDs, first-generation
antihistamines may improve cough