COLDS

The COMMON Cold

• #1 REASON for visits to physicians, #3 for
internists
• 27 million physician visits per year
• 23 million days of work missed
• Average adult has 2-4 colds per year
• $3 billion spent per year on OTC remedies
 Epidemiology
• September through May
• Spread by hand-to-hand contact and
aerosols
 Microbiology
_____________________________________

Virus % of cases

Rhinovirus 30-40
Coronavirus 10-15
RSV
Influenza
Parainfluenza
Adenovirus
Unkown 25-40
 Pathogenesis
• ICAM
• Rhinosinusitis
• Histology of Nasal Epithelium is Normal
• Increased vascular permeability and
secretions
• Components of Snot
• Role of PMNs, Histamine, Kinins, IL
 Approach to the common cold
____________________________________
____________________________________
• H&P
• Diagnosis - consider complications, flu allergy,
strep
• Ascertain Expectations
• Reassure (but don’t minimize)
• Express sympathy
• Educate
• Offer symptomatic relief
 H&P
Symptom Frequency Day
Nasal 45 to 75% 1-2
Discharge
Sneezing
Obstruction
Pharyngeal 35 to 50% 2-3
Sore Throat
Scratch Throat
Cough 40 to 80% 2 -14
Hoarse 15 to 30% 2 - 14
Constitutional 2-4
Feverish
Myalgia
Headache
 Consider Complications
• Bronchitis
• Sinusitis
• Otitis Media
• Pneumonia
• Bronchospasm
 THE TRUE BLUE FLU
Epidemiology
• Usually peaks in January or later
• 20,000 deaths in a typical epidemic season
• 110,000 hospitalizations
• 10%-20% of population infected during
typical season
• When flu epidemic in region, high
percentage of those with ILI have flu
 THE TRUE BLUE FLU
Clinical Presentation
• Classic Flu - sudden onset prostration, high
fever, nasal stuffiness, sore throat, myalgia,
cough and headache
• Study Flu - usually fever + 2 symptoms
• Illness resolves over four to five days
• Cough, fatigue, malaise can linger 2-3 weeks
• Complications - bacterial tracheobronchitis,
sinsusitis, pneumonia
 DIAGNOSIS OF INFLUENZA
Are there pathognomonic symptoms?
Proportion of patients with symptom

• Symptom • With flu Without flu

• Fever (> 37.8) • 68 40
• Feverishness • 90 89
• Cough • 93 80
• Nasal congestion • 91 81
• Weakness • 94 94
• Loss of Appetite • 92 86
• Sore Throat • 84 84
• Headache • 91 89
• Myalgia • 94 94
 DIAGNOSIS OF INFLUENZA
Are there pathognomonic symptoms?
USE OF A CASE DEFINITION AS A
DIAGNOSTIC TOOL
100 patients with a flu-like illness:
T > 37.8
plus 2 of 4: cough, myalgia, sore throat, headache

Case Definition: T > 38 + cough during flu season

Positive Predictive Value 86.8%

Negative Predictive Value 39.3%
Sensitivity 77.6%
Specificity 55.0%
 DIAGNOSIS OF INFLUENZA
INFLUENZA SURVEILLANCE
www.cdc.gov
• WHO - worldwide tracking of drift and shift
• CDC, Influenza Branch
– National Respiratory and Enteric Virus
Surveillance System
– 122 Cities Mortality Reporting System
– State and Territorial Epidemiologists Reports
– US Influenza Sentinel Physicians Surveillance
Network
DIAGNOSIS OF INFLUENZA

RAPID FLU TESTS

 INFLUENZA
Treatment
Drug Trade Name Flu Type Cost Caveat
____________________________________________________

Amantidine Symmetrel A 9.83 Resistance

Generic 1.72 CNS

Rimantidine Flumadine A 18.87 Resistance

Zanamivir Relenza A and B 44.40 Bronchospasm

Oseltamivir Tamiflu A and B 53.00 GI

 INFLUENZA
Prophylaxis

• VACCINATE

• EXPOSURES

• LONGTERM CARE FACILITIES

 Approach to the common cold
____________________________________
____________________________________
• H&P
• Diagnosis - consider flu, bacterial complications,
allergy, strep
• Ascertain Expectations
• Reassure (but don’t minimize)
• Express sympathy
• Educate
• Offer symptomatic relief
 Patients’ Understanding of the
Common Cold
* 87% of people do not seek care for their colds
* In a survey of young adults 94% said it was not necessary
to go to a doctor for a cold.

On the other hand

* Of patients in a clinic for other reasons, 61% said they

would seek care for 5days rhinorrhea, cough, sore throat; if the
discharge were discolored, 79% would seek care.
* 87% of a sample in England thought antibiotics were
beneficial for a cold.
 Patients’ Understanding of the
Common Cold

What Causes a Cold? Antibiotics are helpful for colds

Virus 43.5% Strongly Agree 18.2%
Virus and Bacteria 41.9% Agree 26.1%
Disagree 17.2%
Bacteria 7.9% Strongly Disagree 31.4%
Don’t Know 6.7% Don’t know 7.1%
Factors Correlating with a Desire
for Antibiotics
• Previous Rx for Antibiotic for URI
• Belief they work
• Purulent secretions
• Medicaid
• From a country where abx are OTC
 Why not give antibiotics?
Biggest Risk Factor for developing resistant
S.pneumonia is previous exposure to abx

Good studies show that when overall antibiotic

prescribing is reduced, the prevalence of resistant
strains drops.

About 30% of all the antibiotics prescribed in the US

are for outpatient colds. In many studies, patients
with clear cut colds are Rxed abx 50-60% of the time.

They don’t work

A Multidimensional Intervention
to Reducing Rxs For Antibiotics
• For “Bronchitis”
• Preliminary study found that clinicians code
according to Rx given, not symptoms. The dx
of “chest cold” rather than “bronchitis”
lowered expectations for abx
• Patient and clinician education
• Reduced Rxs for bronchitis from 74% to 48%
 Symptomatic Treatment
Symptom Treatments
Congestion Topical Decongestant
Oral Decongestant

Rhinorrhea Anticholinergic

Sneezing Antihistamine

Cough Suppressant
Tx for Rhinorrhea

Constitutional Acetaminophen
ASA, NSAID
Sore Throat Gargles, Lozenges
Analgesia
 Remedies
• Zinc Gluconate
• Vitamin C
• Chicken Soup
• Vapors
You’ve got the worst cold I’ve
seen all day
Are you miserable?
You look miserable.
I wish we had better treatments

for bad colds

 but as you know

there’s no cure yet

Your cold comes from a viral infection.
Unfortunately,
And furthermore,
YOUR body will fight this off
just like it’s always done.
Your body’s immune system
works best
when you
give it plenty of rest
In the meantime, let’s see if we can
treat the symptoms so you’re not
suffering so much.
If it’s helping, keep taking the oil
of newt
If you get worse,
I HOPE YOU FEEL BETTER
SOON
bye
 NO I AMNOT JUST
GOING TO GIVE YOU THE
ANTIBIOTICS
 Approach to the common cold
____________________________________
____________________________________
• H&P
• Diagnosis - consider flu, bacterial complications,
allergy, strep
• Ascertain Expectations
• Reassure (but don’t minimize)
• Express sympathy
• Educate
• Offer symptomatic relief