Cold season: managing without antibiotics

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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

Antibiotics are usually unnecessary for common “winter illnesses”

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 is snot?”).

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

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.

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 symptoms.

For further information and recommended antibiotic dosing regimens, see: www.bpac.org.nz/antibiotics/guide.aspx

Symptomatic treatment for winter illnesses

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: www.healthnavigator.org.nz

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

Analgesia

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.

Oral decongestants

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 to insomnia.

^* Restricted medicine; products containing pseudoephedrine can be sold in a pharmacy by a registered pharmacist without a prescription.

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: www.healthnavigator.org.nz/medicines/s/saline-nasal-sprays-drops-rinses/

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

Cough syrups

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: www.medsafe.govt.nz/hot/alerts/coughandcold/affectedmedicinesoct2009.asp

Oral corticosteroids

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”, www.goodfellowunit.org/gems/short-term-steroids-may-be-associated-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.

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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.

Coming soon: Winter illnesses clinical audit, see: www.bpac.org.nz/audits