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

Analgesics. Acetominophen, aspirin, ibuprofen, flurbiprofen, and the combination of aspirin and caffeine have all been shown to be effective for sore throat pain in randomized trials.^56-60 Ibuprofen was found to be superior to acetominophen⁶⁰ and aspirin/caffeine was found to be superior to aspirin alone.⁵⁷

Benzocaine. I could find only one study evaluating benzocaine containing lozenges for sore throat⁶¹ and it did not include a placebo group. Although one lozenge (Merocaine) produced significantly better pain relief than the other (Tyrozets), the lack of a placebo comparison makes interpretation of these results problematic.

Cough

Antibiotics. There is no evidence, in the absence of pneumonia or pertussis, that antibiotics are effective for the treatment of acute cough, including cough productive of colored sputum in otherwise healthy patients.⁶² This does not include patients with acute exacerbation of chronic pulmonary disease.

Codeine, Dextromethorphan, Guaifenesin. There are few studies evaluating the effectiveness of cough medicines that contain combinations of guaifenesin and codeine or dextromethorphan. One randomized trial of the effectiveness of codeine for cough related to ARTI showed no difference between experimental and placebo groups.⁶³ Another study found no difference between cough medicines containing guaifenesin alone, guaifenesin and codeine, and guaifenesin and dextromethorphan.⁶⁴ Therefore, although studies are few, there is no evidence to suggest that any of these agents is effective for treatment of cough associated with ARTI. It is interesting to note that all studies showed a marked placebo effect.

b2 -Agonists. Initial studies appeared to show some benefit for inhaled b2-agonists in the treatment of cough.^65-67 A recent systematic review by Smucny, however, found that only patients with demonstrated hyperreactivity of airways benefited from this treatment.⁶⁸

A flow diagram depicting an algorithm for when to use antibiotic in addition to symptomatic treatment for ARTI is shown in the Figure 1. This closely approximates the most recent CDC guidelines on the judicious use of antibiotics for respiratory infections in children and adults. Table 5 summarizes the best clinical trial evidence regarding the use of antibiotics in ARTI.

Prognosis

The mean duration of symptoms for untreated ARTI is approximately 10 days.^38,42,69 It is not unusual for symptoms, particularly nasal congestion and cough, however, to last for up to 3 weeks. One study of lower respiratory tract infection in primary care patients found that 60% were still coughing after 10 days.⁷⁰ Another study of ARTI in children in Norway found that 50% still had nasal discharge and cough after 3 weeks.⁷¹ Complications are rare in primary care patients. Less than 2% of patients with ARTI go on to develop secondary bacterial infection requiring antibiotic treatment.¹ Although there are no data in adults which specifically address whether antibiotic treatment prevents bacterial infection,⁷² there are at least 2 studies that demonstrate that antibiotic treatment of children with undifferentiated ARTI does not prevent pneumonia or otitis media.^73,74