Key practice points:
- Supportive treatment options such as paracetamol, decongestants, adequate fluid intake and rest will provide the best
symptomatic relief for most people with common winter illnesses
- Provide patients with information about the likely duration of their symptoms, e.g. cough can last for up to four
weeks, and ensure they understand when to seek further assessment if their condition deteriorates
- For patients who expect to receive an antibiotic when one is not necessary, discuss why this is not appropriate, including
adverse effects of antibiotics and the self-limiting nature of most winter illnesses
- Antibiotics remain appropriate in some clinical circumstances, e.g. people with suspected pneumonia or pertussis,
some children with otitis media, people with a Group A Streptococcus (GAS) throat infection who are at high risk of rheumatic
fever or in severe illnesses such as bacterial meningitis
Over the winter months, thousands of people across New Zealand will present to primary care with sore ears and throats,
nasal and sinus congestion, coughs and colds*. Many of these symptoms are caused by viral infections and antibiotic
treatment is not appropriate. In some cases there may be bacterial infection present but the infection will be self-limiting
and the adverse effects of antibiotics may outweigh potential benefits. Antibiotic dispensing in New Zealand is 40% higher
in winter than summer months, and it is likely that much of this is unnecessary.1
*For the purposes of this article, this group of symptoms will be referred to as “winter illnesses”,
but it is acknowledged that these illnesses occur at any time of the year.
Asking patients “What would you like me to do for you today?” is a useful conversation opener because it allows the
patient to tell you about their symptoms but can also lead into a discussion about their expectations for treatment. People
generally want relief from their symptoms but they also want to be informed about the likely cause of their illness and
reassured that they have been assessed for other possible diagnoses. Some people will think that they require a prescription
for antibiotics as “they got one last time” or they may think that only antibiotics will provide relief from their symptoms.
Many caregivers, for example, believe that antibiotics are automatically indicated if their child has otitis media, or
people think that having discoloured nasal discharge or sputum means they require an antibiotic (see: “What
Discussion with patients and caregivers may cover:
- What an infection is and how the immune system responds to infection
- The difference between a viral and bacterial infection and the role of antibiotics
- Adverse effects of antibiotics, including gastrointestinal effects, rash, disruption of normal flora (e.g. leading
to Clostridium difficile or Candida albicans infection), antibiotic resistance
- Self-limiting nature of winter illnesses, including expected duration of symptoms
- Symptomatic treatments, e.g. analgesia, decongestants (see: “Symptomatic treatment for winter illnesses”)
- When to seek reassessment, e.g. persistent or worsening symptoms
In many cases, the most important treatment for winter illnesses is effective communication; the patient should leave
the consultation understanding what illness they are likely to have, how long their symptoms should last, what they should
do to manage their symptoms and when to seek further assessment.
For further information about strategies for discussing antibiotics with patients, see: “Antibiotics: the
future is short”, available from: www.bpac.org.nz/2018/antibiotics.aspx
What is snot?
Nasal membranes, like the rest of the upper respiratory tract, are lined with goblet and ciliated cells that produce
mucus. The mucus lining of the nasal cavity traps inhaled particles, viruses and bacteria. The ciliated cells move mucus
down the nasal cavity to the nasopharynx where it is swallowed and enters the gastrointestinal tract (mucociliary clearance).
People usually produce around 1–2 L of mucus over 24 hours, but this volume can double or more if the sinuses or other
parts of the respiratory tract are inflamed, e.g. due to environmental allergens, irritants or infection.2
During infection, the amount of mucus produced is increased to improve trapping and clearance of viruses, and in addition,
mucociliary clearance is disrupted. The excessive mucus from the sinuses that is not swallowed exits the nose (“snot”).
Nasal discharge during an upper respiratory tract infection is a mix of secretions from nasal and lacrimal glands, goblet
cells, plasma cells, inflammatory cells, mucosal epithelial cells and plasma exudates from capillaries.3 The
yellow-green colour of nasal discharge during an upper respiratory tract infection is due to the increased presence of
neutrophils, which contain a green pigmented enzyme.3
The same process occurs with production of sputum from the lower respiratory tract. Mucus is produced in the surface epithelium and
connective tissue, where it keeps the tissue moist to assist the passage of air. Cilia move the mucus up towards the pharynx where
it is swallowed. During infection, the excess mucus that is produced triggers an increased coughing reflex, and the mucus is expectorated
as sputum. Coughing further irritates the respiratory tract and leads to even greater production of mucus. Sputum contains similar
secretions and cells as nasal discharge, including neutrophils.
Therefore, the colour of snot or sputum reflects the severity of an inflammatory response rather than indicating whether an infection is viral
or bacterial.3 Discoloured snot is a non-specific clinical sign and should not be considered a
justification for prescribing or requesting antibiotics.
Ensure people who need antibiotics get antibiotics
While in most cases antibiotics are not required for winter illnesses, there will always be people who do need antibiotics.
The challenge is in identifying these situations. Patient history and clinical features on examination, such as hydration
status, temperature and other vital signs and the presence or absence of chest signs, remain essential to help achieve
a correct diagnosis, assess severity and hence guide appropriate management.
A difficulty is that people can present with symptoms and signs that may suggest a viral upper respiratory tract infection but that also
could be consistent with the early stages of a serious infection, such as pneumonia. It is important to put a “safety net” in place so that
if the person were to deteriorate, further medical assistance would be sought.
Clinical predictors of moderate to severe systemic infection in adults include: respiratory rate > 21–24 breaths
per minute, systolic blood pressure < 90–100 mmHg, heart rate > 90–130 beats per minute, temperature < 36℃
(or fever >39℃).4
Refer to the NICE traffic light system for identifying risk of serious illness in children:
Coming soon: “Sepsis: recognition, diagnosis and early management”, a bpacnz contextualisation
of the NICE clinical guideline, see: www.bpac.org.nz/guidelines
Can CRP levels be used to diagnose bacterial infection?
In bacterial infection, C-reactive protein (CRP) increases within four to six hours of infection and peaks at around
36 hours. The level of elevation usually corresponds to the severity of the infection.5 Bacterial respiratory
tract infections generally cause a greater elevation in CRP than viral infections; CRP < 10 mg/L most likely indicates
a viral infection or a very mild bacterial infection. However, there are some exceptions to this, e.g. a CRP of 10–80
mg/L is not unusual in people with influenza. A person with a severe bacterial infection is likely to have a CRP > 100
mg/L.5 Therefore CRP can be used to assess severity of infection and the higher the value, the more likely
it is a bacterial infection, but there is no particular “cut-off” that predicts bacterial infection with complete accuracy.
In practice, if a CRP level was requested for a patient, it is likely that other parameters would also be investigated
that may add information to the overall clinical picture, such as full blood count including neutrophil, lymphocyte and
Point-of-care testing devices that combine CRP with other biomarkers of infection such as procalcitonin (PCT) and myxovirus
A (MxA) are currently being evaluated for accuracy of predicting viral or bacterial infection.5
For further information on point-of-care CRP testing, see: www.bpac.org.nz/BPJ/2015/June/crp.aspx
Indications for antibiotics
In general, antibiotic treatment for winter illnesses should be considered in people who have a known or likely bacterial
infection and are at increased risk of developing systemic complications; this includes those who are systemically very
unwell, young infants, frail elderly people or those who have co-morbidities such as immune suppression, diabetes or significant
heart, lung, renal, liver or neuromuscular disease. People with a history of hospitalisations and children of premature
birth are also often at increased risk.
Antibiotic treatment is indicated for people with the following infections:6
- Pertussis - antibiotics should be given to reduce transmission if within three weeks of the onset
of cough (or unknown onset, or pregnant women) and for high risk contacts, e.g. infants aged <1 year, pregnant women.
Antibiotics will not alter the course of illness unless given in the first few days of infection.
- Pneumonia – antibiotics are appropriate for all people with suspected pneumonia
Antibiotic treatment may be appropriate in some cases for people with the following infections:6
- Acute otitis media – antibiotics are usually unnecessary as infection will resolve without treatment.
Antibiotics may be considered for children with systemic or severe symptoms, perforation and/or otorrhoea, no improvement
after 48 hours, infants aged under six months or infants aged under two years with bilateral infection. Antibiotics should
also be considered for children with persistent or recurrent infection (≥ 3 infections in six months or ≥ 4 infections
in 12 months).
- Sore throat – antibiotic treatment unnecessary unless Group A Streptococcus (GAS) positive and high
risk of rheumatic fever (personal, family or household history of rheumatic fever or two or more of the following: Māori
or Pacific ethnicity, age 3–35 years, living in crowded/low socioeconomic circumstances), or severe or systemic symptoms,
e.g. quinsy, severe inflammation, scarlet fever.
- Sinusitis – antibiotic treatment is usually unnecessary as most infections are viral and self-limiting.
Intranasal corticosteroids and nasal saline irrigation may be of benefit.7 Antibiotics may be considered for
people with symptoms for > 10 days or severe symptoms, e.g. fever >39°C, facial pain lasting ≥ 3 days, worsening
For further information and recommended antibiotic dosing regimens, see: www.bpac.org.nz/antibiotics/guide.aspx
Evidence shows antibiotics have limited effectiveness for otitis media, sore throat and sinusitis
Acute otitis media: Antibiotics make little difference to the outcomes of children with acute otitis
media in terms of effects on pain, short-term hearing or eardrum perforations.11 A meta-analysis of randomised
controlled trials in children with acute otitis media found an NNT of 24 for a small reduction in pain in children
taking antibiotics compared to placebo at two to three days.12 For further discussion on the efficacy of
antibiotics for acute otitis media, see:
Sore throats: Patients with an acute sore throat will improve after approximately one week, regardless
of whether the infection is viral or bacterial.8 Antibiotic treatment results in only small improvements
in symptoms, on average reducing the duration of a sore throat by 16 hours over seven days.8 A meta-analysis
of clinical trials where adults or children presenting to primary care with symptoms of sore throat were given an
antibiotic or placebo found that after one week, 87% of people with a sore throat taking an antibiotic were free of
symptoms compared to 82% of people taking a placebo, resulting in a number needed to treat (NNT) of 21. Rheumatic
fever prevention should, however, always be considered in people at high risk: personal, family or household history
of rheumatic fever or two or more of the following: Māori or Pacific ethnicity, age 3–35 years, living in crowded/low
Sinusitis: In clinical trials the rate of clinical improvement from seven to 15 days after an infection
ranges from 77–88% with antibiotics compared to 73–85% with placebo treatments.9 Meta-analyses of clinical
trials have found that 18 patients would need to be treated for one patient to have a meaningful reduction in symptom
duration (NNT of 18).10
N.B. The NNTs quoted in relation to the studies above mostly refer to the benefit of antibiotics in
terms of symptom improvement. Reduction in the progression of symptoms and development of complications is also an
important benefit of antibiotics, when indicated.
Bronchiolitis is a lower respiratory tract infection, usually caused by a respiratory virus, therefore
it is not treated with antibiotics. It typically affects children aged under 12 months. Consider the possibility of this
infection in young children with respiratory symptoms. For further information, see: www.bpac.org.nz/2017/bronchiolitis.aspx
What makes decisions about antibiotics so hard?
Winter illnesses can present a challenge for clinicians in primary care, as the decision of whether or not to prescribe
antibiotics is complicated by factors such as:
- Difficulty distinguishing between a bacterial or viral infection; symptoms and signs may not provide reliable differentiation,
point of care testing is not widely available and does not always provide an clear answer
- Concern about missing a diagnosis where antibiotics are required, e.g. bacterial pneumonia
- Determining which patients are most likely to benefit from antibiotics or who may worsen in the absence of antibiotics
as not all patients with bacterial infections require antibiotic treatment
- Whether the patient is able to promptly return for a follow-up assessment if their symptoms worsen if an antibiotic
was not indicated and prescribed at the initial presentation
It is important that people are not inadvertently discouraged from seeking medical attention when they are unwell by
providing negative messages about antibiotic use. Anxiety is one of the key emotions that drives antibiotic use. This
includes both the patient’s anxiety about feeling unwell and not knowing what is wrong with them and also the clinician’s
anxiety about not missing something crucial and wanting to do their best for the patient. Anxiety can act to decrease
understanding of the issues and lead to poor decision making for both patients and clinicians. Clear communication, provision
of symptomatic management advice and a contingency plan are essential components of a non-antibiotic approach to managing
winter illnesses. Many people think that if they do not get prescribed an antibiotic, it means they are not really unwell.
It is important to validate the patient’s decision to seek treatment and explain that viral infections can make people
feel just as unwell as bacterial infections.
Patients and caregivers can be given advice about general supportive measures that may provide symptom relief for winter
illnesses. This includes pharmacological treatments, over-the-counter or home treatments and advice about maintaining
adequate fluid intake, rest and time off work or school, and a warm, dry, smoke-free environment.
Patient information on colds, sore throats, bronchitis and otitis media is available from:
Firstly, provide information on the likely duration of symptoms
A discussion about expected duration of symptoms can help reassure the patient that the course of their illness is normal.
The natural course of symptoms associated with common winter illnesses is usually up to:8, 13
- Three to five days for fever
- One week for headache or sore throat
- A week to ten days for nasal obstruction
- Two weeks for nasal discharge
- Two to four weeks for cough
Paracetamol can be recommended to relieve pain and discomfort associated with respiratory tract infections, e.g. headache,
sinus pain. Mild fever does not need to be treated unless it is causing discomfort; fever is a beneficial immune response.
NSAIDs may also be appropriate for some patients, depending on co-morbidities and hydration status.
Nasal congestion can occur as a result of increased mucus in the nasal cavity and from the dilation of large veins
leading to swelling of nasal tissue.3 This swelling is influenced by sympathetic activity and signals such
as adrenaline or noradrenaline.3 Oral decongestants such as pseudoephedrine*, a sympathomimetic,
therefore may be modestly beneficial in reducing nasal congestion. Phenylephrine may be a less effective
oral decongestant, but it is readily available as a component of several over-the-counter “cold and flu
tablets”. The use of oral decongestants can cause increased blood pressure and tachycardia, and contribute
* Requires a controlled drug prescription and is not subsidised
Nasal decongestants, sprays and rinses
Intranasal ipratropium is fully subsidised and approved for the treatment of rhinitis or rhinorrhoea associated
with the common cold. Evidence from clinical trials shows that intranasal ipratropium is effective at reducing rhinorrhoea
but does not improve nasal congestion. Adverse effects include nasal dryness, nose bleeds and bloody mucus.15
Xylometazoline (Otrivin), a topical nasal decongestant, is available over-the-counter. It is a sympathomimetic
and reduces oedema of the nasal mucosa through vasoconstriction. Patients should be advised that it is only suitable for
short term use (no more than 5–7 days) due to the potential for rebound congestion.
Nasal saline rinses are available over-the-counter, or a solution can be prepared at home and administered
with a suitable device (see below for further information). Saline irrigation thins and enhances the flow of mucus, and
is not usually associated with adverse effects. However, the evidence for benefit is weak as a number of studies have
found that patients on average experience either small or no improvements.16 Saline irrigation may provide
some benefit for patients with sinusitis in conjunction with other treatments.7 Saline rinse or spray is
one of the few treatments that can be safely used in infants.
For further information on performing a saline sinus rinse and making a home-made solution, see:
Intranasal corticosteroids, e.g. fluticasone nasal spray, may improve symptoms in patients with sinusitis
but is unlikely to influence symptom duration, and could cause systemic adverse effects.7, 14 There is no
evidence that intranasal corticosteroids improve symptoms of rhinitis associated with the common cold.
Throat lozenges and sprays
Patients may find over-the-counter lozenges or throat sprays containing an analgesic, NSAID or antiseptic useful; however,
the effect of these medicines may be small and short-lived.8 A range of lozenges and throat sprays with different
active ingredients have been assessed in clinical trials, but there is not enough evidence to determine which of these
are better.8 Lozenges containing flurbiprofen, a NSAID, produce some reduction in pain, however, are likely
to have higher rates of adverse effects than other lozenges, including taste disturbances, numbness, dry mouth or nausea
in 30–50% of people.8
There is a lack of evidence for or against the effectiveness of liquid cough medicines for acute cough.17 This
is largely due to a lack of quality trials that can demonstrate clinically relevant outcomes. Cough and cold medicines
are contraindicated in children aged under six years, and some products, e.g. containing codeine, are contraindicated
in children aged under 12 years.18
A list of cough and cold preparations available in New Zealand with age restrictions is available from:
Oral corticosteroids have been investigated in some clinical trials as a treatment for patients with sore throat, however,
they are not recommended in guidelines due to uncertainties about long-term safety.8 Pooled results from
multiple trials suggest oral corticosteroids can reduce the duration of pain by approximately 14 hours, with a NNT of
4; however, the studies to date have been conducted in patients with severe symptoms, e.g. presenting to emergency departments,
and there is little evidence available regarding possible long-term adverse effects.8
Further reading: “Short-term steroids may be associated with sepsis, thrombosis and fractures”,
Complementary and alternative treatments
A large number of remedies are available for winter illnesses at pharmacies or supermarkets with variable degrees of
evidence for benefit (Table 1 lists some common products). It is likely that some of the perceived benefit of using these
products is due to a placebo effect; for example, patients are more likely to report improvements in their symptoms with
echinacea treatment if they believe that echinacea works.19
Treatments for children: As there are limited options for managing winter illness symptoms in children,
caregivers may wish to trial alternative treatments. There is some evidence that a teaspoon of honey before bedtime may
improve the frequency and severity of cough in children;20 honey is not recommended in children aged under
one year due to a risk of botulism. An aromatic vapour rub applied before bedtime may improve sleep for children and therefore
their parents.21 N.B. Vapour rubs contain volatile oils that may irritate the skin; if this is an issue,
products are available specifically for children that contain lower amounts of irritants, or alternatively, apply the
product to a tissue or handkerchief and place it in a pyjama pocket, inside a pillow case or under the sheets (keep out
of reach of young children).
Health professionals should give unbiased, evidence-based advice (where available) to patients about the treatments
that they are using or wish to trial. Discuss the benefits, or lack of benefits, and the potential harms. Remind the patient
that most winter illnesses are brief and will resolve without treatment.
Table 1: Over-the-counter and self-care treatments for upper respiratory tract and ear infections;
evidence of benefit. N.B. the placebo effect may be a factor in perceived benefit.
|Condition or symptom
||Source of evidence
||Evidence for benefit?
Nasal decongestants, e.g. pseudoephedrine
National Institutes for Health and Care Excellence (NICE) guideline14, systematic review of 15 trials23
Multiple doses may have small beneficial effects, but can cause rebound congestion and should not be used for
more than seven days.
Nasal saline irrigation
Systematic review of five trials16
May produce improvements for some patients, however, the evidence for benefit is weak as a number of studies have
found that patients on average experience either small or no improvements.
Steam inhalation, humidified air
NICE guideline14, Systematic review of 6 trials24
No evidence of benefit or harm due to a lack of studies
Aromatic inhalants, e.g. vapour rub
Single randomised controlled trial21
Compared to either no treatment or a petroleum rub, vapour rub applied at night resulted in improved sleep for
children and therefore parents.
Systematic review of 18 trials25, NICE guideline14
Clinical guidelines do not recommend. No meaningful improvements for individual symptoms such as nasal obstruction,
rhinorrhoea or sneezing, but overall combined severity of symptoms improved in the first few days of use.
Systematic review of 24 trials26
Has not been shown to reduce the incidence or duration of common colds; evidence suggests any benefit is unlikely
to be clinically meaningful.
Zinc lozenges (dissolvable)
Meta-analysis of seven trials27
Data from three trials suggest zinc acetate or gluconate lozenges may reduce cold duration by 2–3 days.27 Studies
used 80–90 mg/day of zinc, which is above recommended upper intake limit of 40 mg for adults.28
Systematic review of 12 trials29
No reduction in duration of symptoms when taken at the time of a cold. Daily use beginning before a cold does
not reduce incidence of colds for the general population but may have an 8–18% reduction in duration of symptoms if
cold occurs. Regular supplementation may reduce the incidence of colds in people engaging in high intensity physical
exercise, e.g. marathon runners.
Probiotics, e.g. products containing Lactobacillus or Bifidobacterium strains
Systematic reviews of 12 trials30, 31
May reduce the incidence of colds and duration of symptoms by approximately one to two days. However, this effect
has not been consistent across different trials.
Over-the-counter cough syrups and suppressants
Systematic review of 29 trials17
There is no clear evidence in favour of cough syrups or suppressants. Cough syrups and suppressants are contraindicated
in children aged under six years or under 12 years if containing codeine or other opioids18
Systematic review of six trials in children20
Honey may improve the frequency and severity of cough; studies mainly assessed the effect of one dose at night
before bedtime in children. Do not use in children aged under one year.
Anaesthetic ear drops, e.g. Auralgan
NICE guideline11, systematic review of five trials32
Anaesthetic ear drops have an NNT of five for a 50% reduction in pain 10 minutes later. The effect is short-term,
however, caregivers may find this useful if despite the use of paracetamol children have significant discomfort and
additional relief is required, e.g. for falling asleep.
Steps patients and caregivers can take to reduce the risk of contracting or spreading upper respiratory tract and ear
infections over winter include:
- Hand washing to reduce the risk of catching or spreading infections; washing with soap and water is sufficient, and
is more effective at prevention the spread of influenza than alcohol hand washes22
- Covering mouth or nose when coughing or sneezing
- Influenza and pneumococcal vaccination*
- Stopping smoking,: smoking is a risk factor for respiratory tract infections13
- A healthy home environment: warm, dry, smoke-free home, warm clothing and good nutrition
* Influenza vaccination is subsidised for pregnant women, people aged 65 years and older and people with eligible conditions.
Pneumococcal vaccination with the PCV10 vaccine is funded for children at ages 6 weeks, 3, 5 and 15 months; vaccination with PCV13 or 23PPV is funded for
children and adults with eligible conditions. See the Immunisation Handbook 2017 for further details:
Coming soon: Winter illnesses clinical audit, see: www.bpac.org.nz/audits