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Upper Respiratory Infection (URI) in Adults and Adolescents

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General Information

Description

  • acute infection of upper airway, generally producing nasal congestion, rhinorrhea, cough, sneezing, sore throat, headache, low-grade fever, and malaise lasting ≤ 2 weeks1,3,6
  • generally self-limiting, mild, and viral in origin1

Also called

  • common cold
  • upper respiratory tract infection (URTI)
  • acute rhinitis
  • acute nasopharyngitis
  • nonspecific upper respiratory tract infection

References

General references used

  1. Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care. Ann Intern Med. 2016 Mar 15;164(6):425-34OpenInNew
  2. Simasek M, Blandino DA. Treatment of the common cold. Am Fam Physician. 2007 Feb 15;75(4):515-20OpenInNewfull-textOpenInNew, editorial can be found in Am Fam Physician 2007 Feb 15;75(4):476OpenInNew, commentary can be found in Am Fam Physician 2007 Oct 15;76(8):1111OpenInNew
  3. Heikkinen T, Järvinen A. The common cold. Lancet. 2003 Jan 4;361(9351):51-9OpenInNew
  4. Scott J, Orzano AJ. Evaluation and treatment of the patient with acute undifferentiated respiratory tract infection. J Fam Pract. 2001 Dec;50(12):1070-7OpenInNew
  5. Bolser DC. Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):238S-249SOpenInNewfull-textOpenInNew
  6. Malesker MA, Callahan-Lyon P, Ireland B, Irwin RS, CHEST Expert Cough Panel. Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. Chest. 2017 Nov;152(5):1021-1037OpenInNewfull-textOpenInNew

Recommendation grading systems used

  • American College of Chest Physicians (ACCP) interpretation of grades
    • strength of recommendation
      • Grade A - strong recommendation
        • quality of evidence good AND net benefit substantial or intermediate, OR
        • quality of evidence fair AND net benefit substantial
      • Grade B - moderate recommendation
        • quality of evidence good AND net benefit small/weak, OR
        • quality of evidence fair AND net benefit intermediate, OR
        • quality of evidence low AND net benefit substantial or intermediate
      • Grade C - weak recommendation - quality of evidence fair or low AND benefit small/weak
      • Grade D - negative recommendation
        • quality of evidence good or fair AND net benefit either none or negative, OR
        • quality of evidence low AND net benefit negative
      • Grade I - no recommendation possible (inconclusive)
        • any quality of evidence AND net benefit conflicting
        • low quality of evidence or only expert opinion AND net benefit none
      • Grade E/A - strong recommendation based on expert opinion only AND net benefit substantial
      • Grade E/B - moderate recommendation based on expert opinion only AND net benefit intermediate
      • Grade E/C - weak recommendation based on expert opinion only AND net benefit small/weak
      • Grade E/D - negative recommendation based on expert opinion AND net benefit negative
    • quality of evidence
      • good - evidence based on good randomized controlled trials (RCTs) or meta-analyses
      • fair - evidence based on other controlled trials or RCTs with minor flaws
      • low - evidence based on nonrandomized, case-control, or other observational studies
      • expert opinion - evidence based on consensus of carefully selected panel of experts in topic field, and no studies meet criteria for inclusion in literature review
    • net benefit
      • substantial - evidence of benefit clearly exceeds minimum clinically significant benefit and evidence of little harm
      • intermediate - clear evidence of benefit but with some evidence of harms, with a net benefit between that defined for "substantial" and "small/weak"
      • small/weak - evidence of a benefit that may not clearly exceed the minimum clinically significant benefit, or evidence of harms that substantially reduce, but do not eliminate the benefit so that it may not clearly exceed the minimum clinically significant benefit
      • none - evidence shows either no benefit or benefits equal harms
      • conflicting - evidence is inconsistent with regard to benefits and/or harms so that net benefit is uncertain
      • negative - expected harms exceed expected benefits to the population
    • Reference - ACCP clinical practice guideline on diagnosis and management of cough (16428686Chest 2006 Jan;129(1 Suppl):1SOpenInNewfull-textOpenInNew)
  • American College of Chest Physicians (ACCP) uses Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system
    • Grade 1A (Strong recommendation, High-quality evidence)
      • benefits clearly outweigh risk and burden or vice versa
      • consistent evidence from randomized controlled trials (RCTs) without important limitations or exceptionally strong evidence from observational studies
      • further research very unlikely to change confidence in estimate of effect
    • Grade 1B (Strong recommendation, Moderate-quality evidence)
      • benefits clearly outweigh risk and burden or vice versa
      • evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise), or very strong evidence in some other form
      • higher quality research may well have important impact on confidence in estimate of effect and may change estimate
    • Grade 1C (Strong recommendation, Low/Very low-quality evidence)
      • benefits clearly outweigh risk and burden or vice versa
      • evidence for at ≥ 1 critical outcome from observational studies, case series, or RCTs with serious flaws or indirect evidence
      • higher quality research likely to have important impact on confidence in estimate of effect and may well change estimate
    • Grade 2A (Weak recommendation, High-quality evidence)
      • benefits closely balanced with risks and burden
      • consistent evidence from RCTs without important limitations or exceptionally strong evidence from observational studies
      • further research very unlikely to change confidence in estimate of effect
    • Grade 2B (Weak recommendation, Moderate-quality evidence)
      • benefits closely balanced with risks and burden
      • evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise), or very strong evidence from observational studies
      • higher quality research may well have important impact on confidence in estimate of effect and may change estimate
    • Grade 2C (Weak recommendation, Low-quality evidence)
      • uncertainty in estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced
      • evidence for ≥ 1 critical outcome from observational studies, case series, or from RCTs with serious flaws or indirect evidence
      • higher quality research likely to have important impact on confidence in estimate of effect and may well change estimate
    • consensus statements - suggestions made in consensus statements are derived through systematic approach and traditional literature review where RCTs and high-quality evidence do not commonly exist, and consensus around the suggestions is achieved using a modified Delphi approach by experts who are carefully screened for conflicts of interest
    • Reference - ACCP expert panel report on pharmacologic and nonpharmacologic treatment for acute cough associated with the common cold (28837801Chest 2017 Nov;152(5):1021OpenInNew)
  • Infectious Diseases Society of America (IDSA) uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system
    • strength of recommendation
      • Strong recommendation - desirable effects of recommendation outweigh undesirable effects or vice versa
      • Weak recommendation - desirable effects closely balance undesirable effects, or appreciable uncertainty in balance of effects
    • quality of evidence
      • High-quality evidence - consistent evidence from well-performed randomized controlled trials, or exceptionally strong evidence from unbiased observational studies
      • Moderate-quality evidence - randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise evidence), or unusually strong evidence from unbiased observational studies
      • Low-quality evidence - ≥ 1 critical outcome from observational studies, randomized controlled trials with serious flaws, or indirect evidence
      • Very low-quality evidence - ≥ 1 of the critical outcomes from unsystematic clinical observations or very indirect evidence
    • Reference - IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults (22438350Clin Infect Dis 2012 Apr;54(8):e72OpenInNewfull-textOpenInNew)
  • American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) definitions for evidence-based statements
    • Strong recommendation - quality of supporting evidence is excellent and anticipated benefits clearly exceed harms; clinicians should follow strong recommendation unless clear and compelling rationale for alternative approach exists
    • Recommendation - quality of evidence not as strong but anticipated benefits exceed harms; clinicians should generally follow recommendation but should remain alert to new information and sensitive to patient preferences
    • Option - quality of evidence suspect or carefully performed studies have shown little clear advantage to one approach over another; clinicians should consider the option in decision-making, patient preference may play significant role
    • No recommendation - lack of pertinent published evidence and anticipated balance of benefits and harms unclear; clinicians should be alert to new published evidence that clarifies balance of benefit and harm
    • Reference - AAO-HNSF clinical practice guideline update on adult sinusitis (25832968Otolaryngol Head Neck Surg 2015 Apr;152(2 Suppl):S1OpenInNewfull-textOpenInNew)
  • American Geriatrics Society (AGS) Beers Criteria grading system for recommendations
    • strength of recommendation
      • Strong - benefits clearly outweigh harms, adverse events, and risks, or harms, adverse events, and risks clearly outweigh benefits
      • Weak - benefits may not outweigh harms, adverse events, and risks
      • Insufficient - evidence inadequate to determine net harms, adverse events, and risks
    • quality of evidence
      • High - evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes, based on either
        • ≥ 2 consistent, higher-quality randomized controlled trials
        • multiple, consistent observational studies with no significant methodological flaws showing large effects
      • Moderate - evidence sufficient to determine risks of adverse outcomes
        • strength of evidence limited by any of
          • number, quality, size, or consistency of included studies
          • generalizability to routine practice
          • indirect nature of evidence on health outcomes
        • based on any of
          • ≥ 1 higher-quality trial with > 100 participants
          • ≥ 2 higher-quality trials with some inconsistency
          • ≥ 2 consistent, lower-quality trials
          • multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects
      • Low - evidence insufficient to assess harms or risks in health outcomes due to any of
        • limited number or power of studies
        • large and unexplained inconsistency between higher-quality studies
        • important flaws in study design or conduct
        • gaps in chain of evidence
        • lack of information on important health outcomes
    • Reference - AGS 2015 updated Beers Criteria for potentially inappropriate medication use in older adults (26446832J Am Geriatr Soc 2015 Nov;63(11):2227OpenInNew), commentary can be found in 27100608J Am Geriatr Soc 2016 Apr;64(4):920OpenInNew

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114537, Upper Respiratory Infection (URI) in Adults and Adolescents; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T114537. Registration and login required.

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