Drug Treatment for URIs: Back to the Drawing Board
Am Fam Physician. 1998 Oct 1;58(5):1066-1068.
Mallory's now legendary explanation of why he was climbing Mt. Everest, “Because it's there,” may also be the only good reason that we have for using antibiotics or other drugs in the treatment of most upper respiratory tract infections (URIs). As is meticulously documented by the collaborative effort of the Centers for Disease Control and Prevention on the judicious use of antimicrobial agents, first appearing in Pediatrics earlier this year1–6 and now published in this and the following issue of American Family Physician7,8 in abbreviated, modified form, antibiotic treatment of many common upper respiratory conditions is unnecessary.
The treatment principles described by Dowell and colleagues,7 which propose setting more stringent limitations on antibiotic use in children, are supported by observations regarding the natural history of such illnesses, among them otitis media with effusion and sinusitis, and by an exhaustive, qualitative review of studies evaluating treatment efficacy.
In other areas of medicine, physicians are admonished for not doing enough—for example, physicians are not adequately prescribing angiotensin converting enzyme inhibitors in the prevention and treatment of left ventricular dysfunction, or multiple-drug therapy for the eradication of Helicobacter pylori. It may be more difficult, however, to convince physicians to do less, when despite our physician's oath to “first do no harm,” our training has always emphasized intervention.
So what should we be prescribing for symptoms of upper respiratory tract infection? According to the evidence, not much. A recent study on antihistamine-decongestant combinations for upper respiratory infections in children shows no difference in symptom improvement between preschool children receiving placebo and children receiving combination treatment.9 In 1997, the Committee on Drugs of the American Academy of Pediatrics issued a statement reviewing the efficacy of antitussive treatments for children and found no well-designed study demonstrating superiority of these preparations over placebo. On the contrary, the only randomized, controlled trial of dextromethorphan, codeine and placebo showed no difference among these modalities in reducing acute cough.10
Adults fare better with the use of decongestants and antihistamines in attaining modest relief of rhinorrhea and reduction of cough. However, the search for additional effective medications to alleviate or shorten the duration of upper respiratory symptoms continues, with contradictory study findings. Recently, a meta-analysis11 of studies on the efficacy of zinc lozenges reported an equal number of trials showing a benefit versus no benefit when compared with placebo. The study concluded that evidence is insufficient to support the routine use of zinc in the treatment of colds.
Bronchodilators have been studied to determine if they have a role in treating acute cough, a condition in which antibiotics have been dismally ineffective. Support for the use of bronchodilators has been contradictory. Two small studies found statistically significant improvement with albuterol (Proventil) over placebo in the treatment of acute bronchitis.12 However, most recently, a study of 104 adults treated with oral albuterol13 showed more side effects and no difference in efficacy between albuterol-treated subjects and control subjects.
Despite weak scientific evidence supporting the use of such adjunct medications in relieving upper respiratory symptoms, over-the-counter remedies are nevertheless used abundantly. One survey14 showed that in a 30-day period, as many as 54 percent of three-year-olds in the United States were given over-the-counter medications, of which two thirds were cough and cold preparations. It is perhaps precisely this lack of efficacy of treatment that drives parents to seek additional relief for their child's symptoms from antibiotic therapy, thus making the physician's job of limiting these agents even more formidable.
Given the physician's limited options in selecting remedies for colds and coughs, especially for children, proper education remains an essential recourse in treating these ailments. Going against most of what for years we have been taught to practice, physicians must now test a new motto: Don't just do something, stand there! The physician must indeed stand his or her ground and help patients understand when pharmacologic intervention does more harm than good. The telephone number given by Dowell7 provides access to educational materials that are useful to both patients and physicians, and may aid well-meaning, caring physicians in avoiding the stigma of therapeutic nihilism. Finally, in weighing the options, the physican may decide that cold remedies in low doses rarely cause dangerous side effects. Recommending them, along with antipyretics, chicken soup and rest, would at least be less harmful than prescribing antibiotics for conditions that do not warrant them.
1. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics. 1998;101:163–5.
2. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101:165–71.
3. Schartz B, Marcy SM, Phillips WR, Gerber MA, Dowell SF. Pharyngitis—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101:171–4.
4. O'Brien KL, Dowell SF, Scwartz B, Marcy SM, Phillips WR, Gerber MA. Acute sinusitis—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101:174–7.
5. O'Brien KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA. Cough illness/bronchitis—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101:178–81.
6. Rosenstein N, Phillips WR, Gerber MA, Marcy SM, Schwartz B, Dowell SF. The common cold—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101:181–4.
7. Dowell SF, Schwartz B, Phillips WR. Appropriate use of antibiotics for URIs in children: part 1. Otitis media and acute sinusitis. Am Fam Physician. 1998;581113–23.
8. Dowell SF, Schwartz B, Phillips WR. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections: part II. Cough, pharyngitis and the common cold. Am Fam Physician. 1998;58:in press
9. Hutton N, Wilson MH, Mellits ED, Baumgardner R, Wissow LS, Bonuccelli C, et al. Effectiveness of an antihistamine-decongestant combination for young children with the common cold: a randomized, controlled clinical trial. J Pediatrics. 1991;118:125–30.
10. American Academy of Pediatrics Committee on Drugs. Use of codeine and dextromethorphan-containing cough remedies in children. Pediatr. 1997;99:918–20.
11. Jackson JL, Peterson C, Lesho E. A meta-analysis of zinc salts lozenges and the common cold. Arch Intern Med. 1997;10:2373–6.
12. Mackay D. Treatment of acute bronchitis in adults without underlying lung disease. J Gen Intern Med. 1996;11:557–62.
13. Littenberg B, Wheeler M, Smith DS. A randomized controlled trial of oral albuterol in acute cough. J Fam Pract. 1996;42:49–53.
14. Kogan MD, Pappas G, Yu SM, Kotelchuck M. Over-the-counter medication use among preschool-age children. JAMA. 1994;272:1025–30.
Copyright © 1998 by the American Academy of Family Physicians.
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