Viral Upper Respiratory Infection

Symptoms

What are the typical early symptoms of an upper respiratory tract infection and how does it progress?

Sore throat, runny nose, and feeling rundown are the most common initial symptoms. Fever, if present, typically occurs during the first few days. Nasal congestion and cough usually come on the second or third day. Many infections improve after seven to ten days. However, some, such as influenza, can have a longer course.

Medically, what makes you worry that this is something that needs more treatment or attention?

Here, the clinician’s mind is usually trying to determine three things: First, is this viral or could it be bacterial? Second, if this is bacterial, does this person need antibiotics to kick it? Third, what are the best supportive therapies for this individual, regardless of viral versus bacterial, based on their symptoms and treatment preferences?  

How do you determine whether the cause is bacterial?

After ten days, about 60% of sinus infections can be considered bacterial. If someone presents with ten days of facial pressure and thick nasal discharge, we’ll consider using antibiotics, though most of those infections would self-resolve even if not treated.  

Fever greater than 102 F for more than two or three days may suggest a bacterial cause (although some viruses such as the flu can have fevers that last five-to-seven days). Persistent sore throat or the inability to swallow can indicate a more severe throat infection that may need prompt medical intervention.

Bronchitis (a chest cold) is almost always viral, but if it’s associated with shortness of breath, night sweats, or high fevers, we start to get concerned about pneumonia, which should be treated with antibiotics. (Additionally, we keep a closer eye on less resilient individuals, including older people and those with compromised immune systems.)

Can you explain how clinicians think about “double worsening” and the trajectory of illness for people with ongoing symptoms?

“Double worsening” refers to a pattern of initial improvement followed by worsening between days five and ten. That’s suggestive of a bacterial cause.

As for ongoing  symptoms, nasal discharge and coughs last the longest. It’s not uncommon for these to linger for several weeks with a viral infection.

Is there evidence for facial tenderness or tooth pain being bacterial versus viral? Any other specific symptoms to pay attention to?

For head colds, facial tenderness or pain radiating to the teeth can occur with both viral and bacterial infections.

As for other symptoms, duration beyond seven-to-ten days, severity, and “double-worsening” are the most important factors in diagnosis. The doctor’s job is to help consider all factors and timelines together to assess clinical likelihood and make real time decisions.  

Can you unpack some of the myths around yellow/green snot and anything else you hear commonly that might mislead people about accurate diagnosis?

Most people assume that snot color carries valuable clinical information. But in truth, it isn’t very telling. Thickness of snot can be helpful, but it still isn’t a great indicator of bacterial versus viral infections.

The duration of a cough is not as big of a determinant as most people suspect, and usually reflects drainage of mucus from the head into the chest. In fact, we expect most coughs to last two-to-three weeks in this context.

Treatment

Is there anything that can be effective in treating an underlying viral infection?

Nasal rinsing with salt water helps the body’s elimination processes, which reduces the risk of bacteria taking hold. But broadly, viruses are always mutating, which is why there aren’t pharmaceutical antivirals for the primary cold-causing viruses.

A few over-the-counter herbs that have evidence for reducing the duration and severity of symptoms are Umcka (Pelargonium sidoides), Andrographis paniculata, and Elderberry (Sambucus nigra)

Is there anything people can do to avoid getting worse?

Definitely get adequate sleep, hydrate, and avoid alcohol. Inhaling hot steam (in the shower or over a bowl) is a favorite strategy for loosening up mucus, though it isn’t as effective as nasal irrigation (such as a saline spray or neti pot). Using a few drops of eucalyptus or thyme essential oil in the steam water is pleasant. However, evidence that it makes a dramatic difference is not really there.

Is there any evidence that taking antibiotics early can help “nip things in the bud”?

Bacterial and viral sinus infections are indistinguishable in the first three-to-four days of illness. A small percentage of people (~5%) might benefit from initiation of antibiotics at seven days of symptoms, but it’s impossible to predict how to choose those individuals.

What’s most effective in helping patients to actually feel better?

Decongestants, either nasal sprays (oxymetazoline) or oral ones (pseudoephedrine) can really help when it’s difficult to breathe from your nose.

Decongestant nasal sprays (as opposed to allergy nasal sprays) should not be used for more than four days consecutively. Longer use will cause the congestion to worsen very soon after stopping.

For coughs, keeping the throat lubricated with lozenges and staying hydrated is best. We sometimes prescribe cough suppressants to relieve a cough when it is impairing daytime functioning or the ability to sleep.

What about the combo over-the-coutner meds (Dayquil, Nyquil, etc)? Are they any good? Is one better than the others?

Combo OTC meds are hard to choose unless you really understand the component medications. Not everyone needs all of those actions in one pill, and the combination can cause unintended side effects. Medications can relieve symptoms, but they won’t typically shorten the course of an infection.

If people would like to take something, it’s typically best to target the symptoms that are most bothersome: Antihistamines will help sneezing and runny nose. Decongestants help congestion. Pain relievers help with aches and pains.

What remedies do you use when you’re sick?  

I generally take inventory of what I have and go buy things I think I’ll need. I start with andrographis pills three times day and nasal rinsing at least twice daily. I also really like to take echinacea as a tincture (liquid from a dropper bottle). I drink hot teas throughout the day, eat warm meals, and use lip balm to prevent my nose from getting raw if I’m frequently blowing it.

Prevention

Is there anything that’s effective in preventing viral infections (beyond behaviors like handwashing)?

First, avoid touching your eyes, face, mouth, or nose with your hands because that’s where you bring germs into your body.

Beyond this, supporting the immune and respiratory functions of the body is the best way to prevent infections from getting bad. You’re more likely to get sicker if your body is rundown when you’re exposed--hence the value of prioritizing sleep, hydration, and general good health during cold season. Regular exercise also primes your body to handle illness more efficiently.  

Is handwashing with soap more or less effective than hand sanitizer for preventing colds?

Whichever option is chosen, thoroughness is important, and cleansing the hands should take at least 15-20 seconds.

Alcohol-based (>60% alcohol) hand sanitizer is a very effective way of killing the viruses that cause most respiratory infections. It also works in a few seconds and is easier to use.

However, washing hands with soap and water is a better way to decrease the number of microbes on the skin, especially if the hands or fingernails are visibly dirty. Additionally, there are a few germs that are not destroyed by alcohol-based hand sanitizer. (We think of those primarily as being diarrhea-causing germs, though there are exceptions.)

In short, they are both effective when done properly, but hand sanitizer might have the convenience edge for cold prevention.

What about vitamin C, echinacea, etc?

If you’re taking supplements, it’s best to initiate them as early in the illness as possible. Research about vitamin C, zinc, and echinacea has suffered from mixed conclusions when multiple studies are lumped together.

In general, vitamin C or zinc may reduce the duration of symptoms by about a day. Echinacea is available in many different formulations, and there isn’t consensus about which part of the plant is best.  

Any interesting evidence for other time-honored approaches (chicken soup, chocolate, etc)?

Chicken soup or other salty/simple broths are great because they’re both hydrating and heating. That combination helps keep the blood circulating and mucus moving.

Inclusion of more vegetables would be the best way to insure a healthy intake of helpful vitamins.

A well-known researcher in the UK has identified chocolate as being an effective addition to cough medicine, partially due to its ability to coat and stick to the throat, where hypersensitive nerve endings trigger cough during illness.

What additional preventive measures do you use?

I stay active, visit a sauna if  I can, and try to spend a minute or two of my showers in cold water to stimulate my immune system. And I've started shifting my winter bedtime earlier to follow natural cycles.

I also begin supplementing with immune supportive products like medicinal mushrooms (available as capsules, tinctures, or throat sprays) and echinacea as soon as I start seeing people around me getting sick.

Of course, flu vaccination is important that time of year as well, especially for older and less healthy people.

Who’s Most at Risk

Are there patients who are more vulnerable to getting serious infections or becoming more ill?

People who suffer from allergies or who smoke, or those who live in places of poorer air quality might be affected more severely by respiratory bugs.

Adults over 65 should be vaccinated for pneumonia, since that population is at higher risk of becoming more ill.

High volume exposure to others’ germs, such as riding busy trains and working in large, open offices can increase the risk of getting a cold in the first place.

Since we don’t have control of all these factors, it’s important to nourish the body with good food and good sleep, and to wash your hands frequently during risky seasons.  

What about specific medical conditions/states that might be worth flagging?

Individuals who have asthma or emphysema, or who are immunocompromised due to medications are more vulnerable because infections can last significantly longer and progress more severely.

Related Topics

How long does a cold last?

What’s the difference between a cold and the flu?

How can you prevent a cold?

For how long is a cold contagious?

What are the best upper respiratory infection home remedies?

Useful Links

Facts on cold symptoms, remedies and prevention (American Lung Association)

Graph with duration of colds (CDC)

Diagnosing and treating sinus infections (American Family Physician)

When to use antibiotics for the common cold (Cochrane Letter)

When to use antibiotics for sinus infections (Choosing Wisely)

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