Evidence-Based Medicine for Student Health Services
Robert J. Flaherty, MD
Swingle Student Health Service
Montana State University
Bozeman, MT 59717

Upper Respiratory Infection
 

Etiology	Monitoring
Epidemiology	Prognosis
Diagnosis	Prevention
Treatment	Patient Education

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Etiology  In this study the etiology of URI was as follows:  Viral etiology - 69%  Rhinoviruses - 52%  Coronavirus OC43 or 229E infection - 8% Influenza A or B virus - 6% Parainfluenza virus, respiratory syncytial virus, adenovirus, enterovirus (total of single infections of each) - 7%  Bacterial etiology - 3.5%  Chlamydia pneumoniae - 2% Haemophilus influenzae -  0.5% Streptococcus pneumoniae - 0.5% Mycoplasma pneumoniae - 0.5% Undetermined etiology - 27.5%  (Includes some multiple etiologies). Caveats Age group: Young adults Type/size: Population study of 200 patients Population characteristics: Patients with URI symptoms Outcome measure: Results of virus culture, antigen detection, PCR and serology with paired samples Diagnostic criteria for URI unclear Not EBM, but interesting Citations Makela MJ et al, Viruses and bacteria in the etiology of the common cold, J Clin Microbiol 1998 Feb;36(2):539-542 - From PubMed     Epidemiology  No evidence is cited.     Diagnosis     No evidence is cited.  Treatment   Antibiotics   Patients who had URI symptoms and positive nasopharyngeal cultures for H. influenzae, M. catarrhalis, or S. pneumoniae reported higher cure rates after amoxicillin-clavulanate. Patients who had negative cultures did not report any benefits from amoxicillin-clavulanate.  Caveats Age group: Adults Type/size: RCT of 314 Outcome measure: Symptom improvement Patients who came to an infectious disease clinic; may not apply to primary care clinics Other antibiotics not studied Citations Antibiotics were ineffective for the common cold unless bacteria were present in nasopharyngeal secretions - Reviewed by Evidence-Based Medicine  Antibiotics used to treat URIs do not prevent subsequent pneumonia.   Caveats Age group studied: Young children Type/size: Meta-analysis Outcome measure: Prevention of pneumonia, not effect on URI symptom intensity or duration Citations Gadomski A M. Potential interventions for preventing pneumonia among young children: lack of effect of antibiotic treatment for upper respiratory infections Pediatric Infectious Diseases Journal, 1993, 12(2), pp. 115-20 - From PubMed  Receiving a prescription for an antibiotic for a URI was not associated with increased patient satisfaction. Better to spend time explaining the nature of a particular illness and the physician's choice of treatment. Caveats Age group: Adults Type/size: RCT of 113 Outcome measure: Patient satisfaction Diagnostic criteria unclear Citations Antibiotic use and patient satisfaction: Review of Hamm RM et al, Antibiotics and respiratory infections: Are patients more satisfied when expectations are met? J Fam Pract 1996;43:56-62 - Reviewed by POEMS/JFP   Similarly: Mangione-Smith R et al, The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior, Pediatrics 1999 Apr;103(4 Pt 1):711-8 - From PubMed  Similarly: Himmel W et al, Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care 1997 Sep;15(3):118-22 - From PubMed    Decongestants/Antihistamines   Chlorpheniramine maleate, pseudoephedrine hydrochloride, oxymetazoline hydrochloride, phenylpropanolamine hydrochloride, ipratropium bromide, and atropine methonitrate, alone and combined with antihistamines, can improve URI symptoms in adults.  Caveats Age group: Adults Type/size: Meta-analysis (19 studies) Outcome measure: Symptom relief Citations Smith MB, Feldman W, Over-the-counter cold medications. A critical review of clinical trials between 1950 and 1991, JAMA 1993 May 5;269(17):2258-2263 - From PubMed  Antihistamines alone probably do not improve symptoms of URIs, and frequently cause somnolence. Caveats Age group: Adults Type/size: Meta-analysis (7 studies - often weak) Outcome measure: Symptom relief Citations Luks D, Anderson MR, Antihistamines and the common cold. A review and critique of the literature, J Gen Intern Med 1996 Apr;11(4):240-244 - From PubMed  On the other hand: D'Agostino RB et al, The effectiveness of antihistamines in reducing the severity of runny nose and sneezing: A meta-analysis, Clin Pharmacol Ther 1998;64:579-96    Other Treatments  Ipratropium bromide nasal spray may offer some minor benefit, although the response may actually be due to the saline vehicle.   Caveats Age group: Adults Type/size: RTC of 411 Outcome measure: Symptom relief Citations Cold Remedies - Reviewed by Bandolier  Zinc salts lozenges do not reduce the duration of common colds. Caveats Age group: Unclear Type/size: Meta-analysis (6 studies) Population: Patients with naturally-occuring colds Outcome measure: Duration of symptoms Citations Jackson JL, Peterson C, Lesho E, A meta-analysis of zinc salts lozenges and the common cold, Arch Intern Med 1997 Nov 10;157(20):2373-2376    Vitamin C, in doses of a gram or more per day, showed a consistently beneficial but generally modest therapeutic effect on duration of URI symptoms (a little less than 0.5 of a symptom day per URI episode). Caveats Age group: Adults Type/size: Meta-analysis (30 trials) Outcome measure: Duration of symptoms Best dosage is not clear Citations Vitamin C for the common cold - Reviewed by  Cochrane    Monitoring    No evidence is cited.         Prognosis      No evidence is cited.         Prevention       Vitamin C, taken prophylactically even in doses of one or more grams daily for several winter months, had no consistent beneficial effect on incidence of URIs. Caveats Age group: Adults Type/size: Meta-analysis (30 trials) Outcome measure: Reduction of incidence of URIs Citations Vitamin C for the common cold - Reviewed by  Cochrane     Patient Education  The following patient education materials are consistent with the available evidence. Colds and Flu - From Group Health Cooperative  The Common Cold - From the MSU Student Health Center  Cold and Flu Self-Care Flowchart - From AAFP  The Common Cold - From the NIAID Is It a Cold or the Flu? - From the NIAID  Fever Self-Care Flowchart - From the AAFP  Cough Self-care Flowchart - From the AAFP  Nausea and Vomiting Self-Care Flowchart - From AAFP Careful Antibiotic Use - From Rensselaer Polytechnic Institute Student Health Center Antibiotics: When They Can and Can't Help - From the AAFP Rev. 10/20/01

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