Clinical Practice Guidelines

Acute Upper Respiratory Tract Infection

This guideline is designed to help the health care practitioner with screening guidelines for colorectal
cancer and is not intended to replace the practitioner’s judgment in the office setting.
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Sources:
Colorado Clinical Guidelines Collaborative (CCGC): Management of Acute Upper Respiratory Tract
Infection, 2000
Health Plan Committee Review: Physician Advisory Committee (PAC)
Date Adopted: 2000
Revision Date: February 2002, April 2004, February 2006
Line(s) of Business: HMO Colorado and HMO Nevada

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® Registered marks Blue Cross and Blue Shield Association.
 Page 1
The
Colorado
Clinical
Guidelines MANAGEMENT OF
Collaborative ACUTE UPPER RESPIRATORY TRACT INFECTION
A Clinical Guideline from
The Colorado Clinical Guideline Collaborative

Introduction
Enclosed you will find a practice guideline for the management of acute respiratory infections in
adults, along with algorithms that begin with three of the most common patient symptoms –
cough, sore throat, and acute nasal/sinus congestion. The following diagram describes the
guideline organization:
Acute
Respiratory
Illness

Cough Sore Acute Nasal/Sinus

Throat Congestion

Syndromes will occasionally overlap, and this guideline is not intended to imply otherwise.
Many of the principles and references discussed apply to pediatric populations, particularly the
approach to sore throat which has been most thoroughly studied in the pediatric literature.
However, problems unique to pediatrics are not within the scope of this guideline and are not
addressed.
The guideline is important for two reasons. First, it describes the preferred methods of diagnosis
and treatment for problems that physicians encounter daily. Secondly, management of acute
respiratory infections varies widely and can include inappropriate treatment – especially the use
of antibiotics. Antibiotic use, when not indicated, and the use of second and third line antibiotics
when first lines are appropriate, is creating a serious public health problem – the development of
antibiotic-resistant strains of bacteria. In the Denver metro area, penicillin non-susceptibility
rates among invasive pneumococcal isolates have increased from an estimated 4% in 1981 to
14% in 1994 to 22% in 1998-99. The Centers for Disease Control has expressed deep concern
over inappropriate antibiotic use, especially for acute respiratory infections. This guideline
reflects that concern. Please note that, in most instances, antibiotics are not recommended for
these conditions. In circumstances where antibiotics are recommended, first-line agents are
nearly always used.
The appropriate use of antibiotics is not only a public health priority; it constitutes the best care
for your patient. Infections caused by resistant organisms are more common among patients who
have recently received antibiotics, as well as their close contacts. Avoiding antibiotics when they
are not necessary also prevents other antibiotic-associated complications and is in accordance
with the physician dictum, primum non nocere (first do no harm).
Studies have shown that, although patients frequently expect antibiotics for upper respiratory
infections, their satisfaction with their physician is not dependent on receiving antibiotics but
rather on how well the physician explains the appropriateness of the recommended treatment.
Therefore, we have included a patient education sheet created by the Colorado Department of
Health that reinforces the treatment options described in the guideline. You may find this helpful
when you discuss treatment options with your patients.

This guideline is designed to assist the clinician in the management of acute upper respiratory tract illness. This guideline is not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition. For further
information about CCGC or this guideline, go to www.coloradoguidelines.org.
 Page 2

APPROACH TO ACUTE COUGH ILLNESS

Acute Cough Illness

in the Healthy Adult (1)
(< 3 weeks;
with or without phlegm)

Vital Sign Abnormalities

HR>100; RR>24; or
T>38 C (100.5 F) (2)
present
absent

Consider chest x-ray Physical Exam Abnormalities

(r/o pneumonia) suggestive of consolidation or
pleural effusion

present absent

Acute Bronchitis (chest cold):

Symptomatic Treatment
positive
CXR negative Expectoration
CXR • increase fluid intake
• humidify air
Cough Relief
• dextromethorphan, or codeine
• bronchodilator (if wheezing,
Treat decreased peak flow present)
Pneumonia Pain Relief
• NSAID or acetaminophen

Footnotes
(1) Smokers without underlying lung disease should be managed similarly to the nonsmoking population. The
encounter provided an opportunity to discuss smoking cessation.
(2) If the duration of illness is > 2 weeks, consider pertussis. PCR or culture testing for pertussis is done to confirm
the diagnosis and indicate the need for public health follow-up to prevent illness among contacts, especially infants.
Antibiotic therapy can decrease shedding, but has no effect on symptoms during the paroxysmal phase (> 10 days
after illness onset).

This guideline is designed to assist the clinician in the management of acute upper respiratory tract illness. This guideline is not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition. For further
information about CCGC or this guideline, go to www.coloradoguidelines.org.
 Page 3

Acute Bronchitis in the Healthy Adult

Acute bronchitis is a clinical diagnosis based on the presence of an acute/subacute cough

illness, often with sputum production. The etiology and management of acute bronchitis in
adults with chronic lung disease, the elderly, young children and infants, and the
immunocompromised host is different from the otherwise healthy adult, and is not addressed in
this guideline.

The primary goal in evaluating patients with acute cough illness is to rule-out pneumonia
(clinically or radiographically).

Acute bronchitis has a viral or non-bacterial etiology in over 90% of cases under usual
circumstances. The most common viral pathogens include influenza, parainfluenza, RSV,
coronavirus and rhinovirus. The only proven bacterial causes of acute bronchitis are atypical
pathogens such as Mycoplasma pneumoniae, Chlamydia pneumoniae (TWAR), and Bordetella
pertussis. The only distinguishing feature of bacterial bronchitis is that patients seek care late in
the illness (2-3 weeks after onset), and antibiotic treatment is unlikely to promote symptom
resolution. When pneumonia has been ruled-out, fever, purulent sputum, wheezing and other
clinical features are equally prevalent in viral and bacterial bronchitis. Sputum gram stain or
culture is of no apparent benefit. Smokers without underlying lung disease will often have a
longer course of illness, but this is not indicative of bacterial infection and does not warrant
antibiotic therapy. An encounter with smokers in this setting presents an opportunity for smoking
cessation counseling.

Therefore, antibiotic treatment is not recommended, and 8 randomized, placebo-controlled

trials have confirmed no meaningful clinical benefit of antibiotic treatment for acute
bronchitis in the healthy adult. Only a single trial analyzed a sub-group with Mycoplasma
infection, and showed no symptomatic benefit to antibiotic treatment.

Rare circumstances, such as suspected pertussis outbreak, warrant antibiotic treatment to

decrease bacterial shedding, but will usually not lead to symptom resolution. If pertussis is
suspected, obtain a clinical specimen for diagnostic testing by culture or PCR. You may contact
the State Heath Dept. for assistance. Pertussis is a reportable condition in Colorado and warrants
public health follow-up.

The nagging cough of acute bronchitis results from inflammation of the bronchi and
bronchioles, and is often accompanied by bronchial hyperresponsiveness. As a result, the
cough usually doesn’t peak until several days after illness onset, and usually lasts 1 to 3 weeks.

Albuterol MDI may decrease cough severity and duration some patients. In contrast to
antibiotics, beta-2-agonists have demonstrated efficacy in randomized controlled trials against
placebo and against erythromycin. If wheezing is prominent in association with acute bronchitis,
consider a follow-up evaluation for asthma after the resolution of acute symptoms.

This guideline is designed to assist the clinician in the management of acute upper respiratory tract illness. This guideline is not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition. For further
information about CCGC or this guideline, go to www.coloradoguidelines.org.
 Page 4

APPROACH TO ACUTE SORE THROAT

Acute
Sore Throat
<10 days

History and Examination

Fever (> 38.5o) or
Lymphadenopathy
or Exudate or known Strep
exposure

Any Present Ψ Absent

Rapid Strep
Antigen Test† or Symptomatic
Culture Treatment

Positive Negative

Treatment with Penicillin Culture if the clinical picture

Positive
or Erythromycin strongly suggests GABHS (if
(PCN allergic) or Culture not yet cultured) and Treat
Cephalexin (for non- Symptoms
anaphylactic
PCN allergy), and
symptomatic treatment Symptomatic Treatment

Salt-water gargles
Acetaminophen
NSAIDs (Aspirin in adults)

Footnotes
†
See appendix for the sensitivity and specificity of rapid tests
* Do not treat with antibiotics unless rapid antigen test or culture is positive.
Ψ The specificity of the clinical picture for GABHS is increased if 3-4 features are present.

This guideline is designed to assist the clinician in the management of acute upper respiratory tract illness. This guideline is not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition. For further
information about CCGC or this guideline, go to www.coloradoguidelines.org.
 Page 5

Pharyngitis

Classic symptoms of pharyngitis include acute onset of pharyngeal pain, dysphagia, and
fever (usually from 101º to 104º). Rhinorrhea, cough, hoarseness, conjunctivitis and diarrhea
are rare, and, if present, strongly suggest a viral etiology. On examination, the pharynx may be
erythematous, and have a patchy exudate on the posterior pharynx and tonsils. Anterior cervical
lymphadenopathy is common.

Most cases of pharyngitis are caused by viruses. The most common infections are due to
rhinovirus, coronavirus, influenza A and B, coxsackievirus and parainfluenza virus. Group A
beta-hemolytic Streptococcus (S pyogenes, GABHS) accounts for 10%-15% of cases of
pharyngitis in adults. GABHS can be cultured from about 30% of cases of sore throat in children,
and about half of these children (15%) have a significant bacterial infection on the basis of
serological studies. Other causes are cytomegalovirus, Epstein-Barr virus (infectious
mononucleosis), adenovirus, herpes simplex virus, and, less commonly, group C and G
Streptococcus, Neisseria gonorrhoea, Mycoplasma pneumoniae, and Chlamydia pneumoniae. As
with the viruses, the other beta-hemolytic streptococci (group C and G) have a self-limited
course, and do not cause Rheumatic Fever.

Clinically, streptococcal pharyngitis can be indistinguishable from viral pharyngitis,

although GABHS is rare when fever, lymphadenopathy and exudate are not present.
Making the diagnosis of GABHS pharyngitis is important in the prevention of rheumatic fever.
Prophylaxis with appropriate antibiotics within nine days of onset of symptoms can prevent
progression to rheumatic fever. Early treatment may have a modest effect on system duration and
decrease the risk of suppurative complications, such as peritonsillar abscess and retropharyngeal
abscess. Patients with typical viral upper respiratory infection symptoms (e.g., cough, rhinorrhea,
etc.) are unlikely to have GABHS and do not require diagnostic measures for GABHS.

The diagnosis of GABHS can be made reliably with culture but these results are generally
not available for 24-48 hours. Antibiotics should not be prescribed in the absence of
laboratory confirmation of GABHS infection. The development of rapid antigen tests for S.
pyogenes may expedite the diagnosis, allowing some patients to leave the office with the
appropriate treatment. See the chart in the appendix for a description of sensitivity and specificity
of different available tests. Given the lower sensitivity of the rapid test, pharyngeal culture is
warranted in individuals with a suspicious clinical picture and a negative rapid strep test.

Treatment of GABHS should be with Penicillin (dosed 2-3 times daily) for 10 days, or a
single IM injection of benzathine penicillin. Amoxicillin is an acceptable alternative, but the
American Academy of Pediatrics (AAP) and the CDC have recently recommended a second line
status for amoxicillin in pharyngitis because of greater selective pressure for resistant flora. Once
daily amoxicillin may be as effective as TID therapy in children, but more studies are needed
before it can be recommended as first line therapy. To date no GABHS resistance to beta-lactam
antibiotics have been identified. Erythromycin is the drug-of-choice for penicillin allergic
individuals and cephalexin can be used for patients with non-anaphylactic penicillin allergy.

The American Academy of Pediatrics, CDC, American Association of Health Plans and
Infectious Diseases Society of America recommend treating only individuals with a positive
laboratory test with antibiotics. Newer higher sensitivity tests (e.g., newer optical
immunoassays) do not change the recommendations to culture individuals with a negative rapid
test and a clinical picture strongly suggesting GABHS.

This guideline is designed to assist the clinician in the management of acute upper respiratory tract illness. This guideline is not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition. For further
information about CCGC or this guideline, go to www.coloradoguidelines.org.
 Page 6

APPROACH TO ACUTE NASAL AND SINUS

CONGESTION
Acute Infectious
Rhinosinusitis
Stuffy nose
Nasal discharge
Facial pressure
Any duration
<7-10 day
(uncommon)
duration
7-10 day duration
without improvement
Uncomplicated URI- or distinctly biphasic * Acute Focal Sinusitis
associated rhinosinusitis
Acute presentation:
Nonresolving or facial pain with
worsening rhinosinusitis toothache, unilateral
redness; facial edema,
and/or fever >38 degrees
Symptomatic Therapy
Nasal saline lavage
Decongestants First-line antibiotic agent
Antihistamines (first generation) may be elected (use
NSAIDs and acetaminophen second line agents for
Guaifenesin treatment failure or severe
disease).
Symptomatic therapy

Serious infection
should be treated
Milder focal sinusitis
with amoxicillin-
requiring treatment may
clavulanate, a
respond to amoxicillin or second generation
co-trimoxazole, using a cephalosporin, or
second-line agent for
parenteral therapy as
treatment failure.
necessary.
Immediate sinus
drainage may be
indicated.

* a biphasic illness refers to a definite worsening of sinus symptoms

following improvement or recovery.

This guideline is designed to assist the clinician in the management of acute upper respiratory tract illness. This guideline is not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition. For further
information about CCGC or this guideline, go to www.coloradoguidelines.org.
 Page 7

Rhinosinusitis

Rhinosinusitis refers to acute inflammatory symptoms of the nose and/or sinuses. In most
instances, it is not possible to separate symptoms resulting from nasal vs. sinus pathology. Even
when sinusitis is established, bacterial and viral causes may be indistinguishable. Common
symptoms include sneezing, rhinorrhea, nasal obstruction, facial pressure and headache.

The most common scenario involves acute rhinitis and pansinusitis. The traditional teaching
of “acute sinusitis” as a bacterial infection has resulted in some confusion since we now know
that viral rhinosinusitis is common. In 87% of cases, the common cold is accompanied by
demonstrable sinus cavity disease, and only 0.5 to 2.0% of these cases are complicated by
bacterial infection. Sinusitis associated with viral URI is typically self-limited; initial antibiotic
therapy is not indicated. Bacterial infection may be suspected if symptoms of rhinosinusitis fail
to resolve as expected or if a distinctly biphasic course of illness is present. About 60% of
cultures taken after 7-10 days of symptomatic acute rhinosinusitis yield bacteria. Even in these
persistent cases, symptoms improve or resolve in 69% of patients without any antibiotic
treatment, probably more frequently if sinusitis is diagnosed clinically. Among the remaining
patients, antibiotic therapy decreases the rate of persisting or worsening of symptoms by half.
Therefore, after a week or more of symptoms, antibiotic therapy may reasonably be elected if
improvement has not begun. In this setting, first-line agents should be employed initially if
antibiotics are used. Amoxicillin and trimethoprim-sulfamethoxazole (co-trimoxazole) have
performed as well as newer antibiotics in controlled clinical trials. A more severe presentation
may justify using a second-line agent (e.g., amoxacillin/clavulanate) initially.

Acute Focal Sinusitis constitutes a small minority of these presentations. More specific
indicators of bacterial infection may be present at onset. Most commonly, there is a single site of
acute facial pain with swelling, facial edema, toothache, redness, and/or fever. In these more
severe infections, immediate use of antibiotics active against Streptococcus pneumoniae,
Hemophilus influenzae and Moraxella catarrhalis is appropriate. Co-trimoxazole or amoxicillin
may be suitable for mild or equivocal cases, or high-dose amoxicillin for children in regions
where intermediately resistant S. pneumoniae are common. For more severe infection and
nonresponders, ß-lactamase-stable cephalosporins that are active against pneumococci or
amoxicillin-clavulanate should be used, and intravenous therapy should be started for severe
infection or the suspicion of intracranial or orbital extension of infection. If dental infection or
extraction preceded maxillary sinusitis, the antibiotic spectrum should include oral anaerobes.

A variety of non-antimicrobial therapies may also be employed in acute rhinosinusitis.

Nasal decongestants may alleviate symptoms. Because the passage between the sinuses and the
nasal cavity does not have a vasoactive epithelial layer, decongestants do not demonstrably
impact sinus drainage. First generation antihistamines have been shown to alleviate rhinorrhea
and sneezing, but not other symptoms of the common cold. Second-generation antihistamines
lack anticholinergic activity and are less effective at drying secretions. Concerns on theoretical
grounds that drying secretions would complicate or prolong colds, worsening the overall illness,
have not been supported in controlled studies. Nonsteroidal anti-inflammatory drugs are useful in
treating systemic symptoms and may also reduce the frequency of cough, but aspirin should be
avoided in pediatric patients. Guaifenesin has a clinically small but statistically significant impact
on thinning secretions, and has been used on theoretical grounds.

Nasal drainage procedures, such as saline lavage, may assist in clearance of secretions.
Steam inhalation, environmental humidification and drinking plenty of water may also help clear
secretions and provide comfort.

This guideline is designed to assist the clinician in the management of acute upper respiratory tract illness. This guideline is not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition. For further
information about CCGC or this guideline, go to www.coloradoguidelines.org.
 Page 8

APPENDIX
Rapid Streptococcal Antigen Tests
TEST 1 TEST 2 TEST 3
Sensitivity* 79 (58-97) 79 (61-96) 89 (77-99)
Specificity* 95 (76-100) 95 (63-100) 93 (62-99)
*mean values and (range)
Test 1: Latex Agglutination-Based Rapid Streptococcal Tests
Test 2: Enzyme-Linked Immunosorbent Assay-Based Rapid Strep Tests
Test 3: Optical Immunoassay Studies

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This guideline is designed to assist the clinician in the management of acute upper respiratory tract illness. This guideline is not
intended to replace a clinician’s judgement or to establish a protocol for all patients with a particular condition. For further
information about CCGC or this guideline, go to www.coloradoguidelines.org.