Evaluation and Treatment of the Patient with Acute Undifferentiated Respiratory Tract Infection

Echinacea. Echinacea was evaluated in another Cochrane Library Systematic Review.³⁹ Sixteen trials were evaluated, two thirds of which had insufficient quality of reporting. There were many different extracts used, which made comparability of the results a problem. Most trials showed positive results, suggesting that preparations containing extract of echinacea may have some beneficial effect on prevention and treatment.

Intranasal Fluticasone. Intranasal fluticasone was evaluated in a randomized trial of 200 young adults with common cold symptoms.⁴⁰ No clinically significant differences were noted in either duration or severity of symptoms between treatment and control groups.

Nasal Discharge

Antibiotics. As noted above under undifferentiated ARTI, a Cochrane systematic review of randomized antibiotic trials found no evidence of benefit of antibiotic treatment for clear or purulent rhinnorrhea.²⁸ Another Cochrane systematic review focused on randomized trials of antibiotic treatment for sinusitis.⁴¹ There was modest benefit from amoxicillin treatment in patients with acute maxillary sinusitis confirmed radiographically (NNT=4). There was no evidence, even from more recent studies, that other antibiotics were any more effective than amoxicillin. Lindbaek was able to demonstrate in a randomized controlled trial of amoxicillin that the only patients who benefited from treatment were those who had either complete opacification of a sinus, or an air fluid level.⁴² Patients who had mucosal thickening alone showed no difference from the placebo group. Of the patients in the placebo group who did have opacification or air fluid level, half were well or much better within 10 days. There is also some evidence that patients who present with moderate to severe unilateral facial pain benefit from antibiotics.⁴³ In children, a recent antibiotic trial of patients who had a clinical diagnosis of sinusitis with symptoms for between 14 and 28 days showed no difference in any outcome measure between treatment and placebo groups.⁴⁴

Based on Lindbaek’s data for adults, assuming that 42% of patients with suspected bacterial sinusitis actually have the disease, the number needed to treat to benefit one patient is 8. The number needed to harm by adverse effects from antibiotics is 4, so harm may outweigh any benefit. Frontal sinusitis seems to represent a different disease process because of the anatomy of drainage from the frontal sinuses. These patients usually present with high fever, severe pain, are quite ill, and may require hospitalization, parenteral antibiotics and surgery.^1,45,46 A practical approach is to treat all patients with nasal discharge symptomatically, unless they have severe pain, or appear very ill, in which case sinus films should be considered to rule out frontal sinusitis, or opacification or air fluid level in any sinus. Also, adult patients who have had sinus symptoms for more than two weeks without improvement are more likely to benefit from antibiotic treatment.⁴²

Ipratropium. Ipratopium nasal spray used in a randomized controlled trial, reduced rhinnorrhea and sneezing in patients with cold symptoms by 31% compared to placebo saline nasal spray (ARR=16% NNT=7), and by 78% when compared with untreated patients (ARR=63% NNT=2).⁴⁷

Brompheniramine. Brompheniramine likewise has a temporary modest effect on rhinnorrhea in adults. Brompheniramine was evaluated in a randomized controlled trial in volunteers infected with rhinovirus.⁴⁸ The treatment group had a 20% reduction in symptom score on day 1 and a 26% reduction on day 2. The main symptoms improved were sneeze frequency, sneeze severity, and cough count. Drowsiness was a troubling side effect. Neither decongestants nor antihistamines, nor combinations of the 2 have shown any effect in randomized trials in children.⁴⁹

Nasal Decongestants. The efficacy of oral psuedoephedrine or metalazone nasal spray were evaluated in a Cochrane Library meta-analysis.⁵⁰ There was a 13% reduction in symptom score (subjective rating of severity of nasal congestion) after a single use of either agent, but no difference in combined symptom scores after use for 5 days.

Heated Humidified Air. Published studies of effectiveness of breathing heated humidified air for cold symptoms were evaluated in a Cochrane Library Systematic Review.⁵¹ Six studies were evaluated and the results were quite heterogeneous. One study in Israel and two in the UK showed significant improvement, while three in the US showed no difference between treatment and placebo groups.

Sore Throat

Antibiotics. The data for sore throat should reassure physicians who worry about the consequences of missing streptococcal pharyngitis. A Cochrane meta-analysis showed that treatment of streptococcal pharyngitis with penicillin did reduce duration of illness, but only by approximately half a day.⁵² There was only a minimal effect on prevention of suppurative complications as well (NNT=30 for children and NNT=145 for adults to prevent one case of otitis media). The incidence of rheumatic fever is so low in the industrialized world (.5 per 100,000 in the pediatric population in the United States )⁵³ that the number needed to treat to prevent 1 case of rheumatic fever is exceedingly high. In fact, Howie⁵⁴ has estimated that for a general practitioner in Scotland the NNT exceeds the number of patients he or she would see in his or her lifetime. Furthermore, it is estimated than only approximately 15% of patients with streptococcal pharyngitis ever present for treatment, further reducing the opportunity to prevent complications.⁵² Most of the symptomatic improvement from antibiotics comes in the first 3 days of illness, so that if culture is used as a treatment criterion, most patients will already be better by the time the results are available.⁵⁵