Direction of pathogen propagation

Respiratory tract infections generally start in the nasopharynx, where rhinopharyngitis develops with rhinitis (head cold), sore or raw throat and fatigue. Subsequently, the course depends on the direction of propagation of the pathogens (Fig. 2) [9].

Ascent = sinusitis.

Descent = bronchitis, often in conjunction with tonsillitis or laryngitis.

Acute Respiratory Tract Infections:
Therapy Options for Adults and Children

Acute respiratory tract infections are among the most common diseases in general practitioner and pediatric practice. They occur most often in the winter months and can account for up to 50% of all medical consultations during epidemics [1].

This CME provides information of acute respiratory tract infections in adults and children, pathogenesis and diagnostics, as well as non-drug and medicinal therapy (with phytopharmaceuticals also).

Author
Prof. Dr. med. Matthias Tisch, Bundeswehrkrankenhaus Ulm, Klinik und Poliklinik für HNO Heilkunde

Review
Dr. med. Thomas Feilscher, Hamburg
Dr. med. Alexander Voigt, Würzburg

EACCME
European Accreditation Council
for Continuing Medical Education

1 Epidemiology and economic significance of the common cold

Acute respiratory tract infections are among the most common diseases in general practitioner and pediatric practice. They occur most often in the winter months and can account for up to 50% of all medical consultations during epidemics [1].

Acute respiratory tract infections

• lead to high direct and indirect costs [2]
• are often the cause of absence from work [3]
• are the second most frequent cause of workplace absence [7]

2 Pathogens and pathogenesis

Viruses are the cause of 90-95% of all cases of respiratory tract infections.

• adenoviruses
• coronaviruses
• influenza viruses (A, B)
• para-influenza viruses
• respiratory syncytial virus (RSV)
• rhinoviruses
• humane metapneumovirus

Longitudinal cohort studies have shown that only 8% of all acute respiratory infections have a bacterial origin [8].

Infection

The basis of every infection is a disturbed immune balance. The immune system is weakened by:

• external factors
  • dry heated air
  • clammy cold weather
• immune-modulating processes
  • reaction to stress

The pathogens bypass the immune defense system by particularly rapid replication. An infection develops in three steps in the course of the interaction with the epithelial cells.

Pathogens internalized in deeper cell layers, in particular, are a reservoir for prolonged courses and recurrences of respiratory tract infections.

Video: Acute respiratory tract infection

3 Clinic

3.1 Common cold (flu-like infections)

The most frequent infections are uncomplicated respiratory tract infections (such as the common cold or flu-like infections).

• Young children are affected up to thirteen times a year.
• Adults are affected on average two to four times a year.

Typically, rhinovirus infections of the upper air passages are isolated infection sources in the epithelium. There are hardly any cytopathic changes [11].

One to two days after infection: symptoms of common cold occur.

Three to four days after infection: rhinorrhea reaches its high point.

Fever: occasional, although unusual in adults.

Up to five days after infection: inflamed throat develops.

An ordinary common cold lasts one week; in 25% of the cases, it lasts up to two weeks.

3.2 Sinusitis

Acute sinusitis is a mucous membrane inflammation in the paranasal sinuses. The maxillary sinus is usually affected in adults. Most cases of acute sinusitis are caused

• by rhinoviruses
• (seldom) adeno, parainfluenza or influenza viruses [13]

The virally-induced mucous membrane damage can lead to an additional bacterial infection in the paranasal sinus cavity. A swab can be used to clarify whether or not bacteria are involved. The symptom complex of acute sinusitis generally persists for less than two weeks. Biopsy samples show increased mucus production and increasing mucous membrane inflammation with cell infiltration.

The relatively pronounced epithelia cell destruction in the sinus is in contrast to the rather minor epithelial cell destruction in the nasopharyngeal region and in the mucous membrane of the lower respiratory tract [14].

3.3 Pharyngitis, tonsillitis

Acute pharyngitis and tonsillitis as inflammation syndromes of the oropharynx can be pathogen-dependent exudative or nonexudative. Many mild pharyngitis cases are caused by rhino and corona viruses. The pharyngitis caused by adenoviruses and HSV is less frequent, but more severe in its course. The pathogenesis is different for the different viral pathogens and may or may not be accompanied by the destruction of mucous membrane tissue.

During common colds, the throat often shows mild signs of edema and erythema. The pharyngeal complaints persist for some days and subside for most patients at the latest after one week.

3.4 Bronchitis

Incubation period: two to six days in adults

Symptom complex: lasts about four to six days. Coughing can persist for several weeks, however, primarily with an influenza virus infection.

Chronic Bronchitis: coughing and sputum production persist for at least three months within two consecutive years.

Acute exacerbation of chronic bronchitis:
one to four times per year, accompanied by increasing coughing, acute respiratory distress, tiredness and acute inflammation. Up to 64% of the virally-induced exacerbations of chronic obstructive bronchitis are associated with the common cold [15].

Among older people who suffer from a common cold, two-thirds develop a disorder of the lower air passages (trachea, bronchi and lungs); this rises to four‑fifths if influenza viruses or RSV are the cause of the cold. Rhinoviruses are involved in 65% of cases. All respiratory viruses can trigger severe illness in persons at risk that can sometimes be worsened by bacterial superinfection. Smoking increases the risk of diseases of the lower respiratory tract [13, 16].

3.5 Special considerations for children

A Finnish study identified rhinoviruses as the cause of the majority of common cold infections but newer viruses such as hMPV, Boca virus or new corona viruses increasingly play a role [18].

The clinical course in children varies with the causal virus. Complaints increase for two to three days and subside by the seventh day of illness. In particular, small children can be ill for up to two weeks.

Acute RTIs can lead to difficulty in swallowing and respiratory disorders in babies by hindering nasal respiration. Often, pharyngitis is the first symptom, followed by a congested nose, rhinitis (head cold) and coughing. Moderate fever frequently accompanies the course of the disease. For young children, it is occasionally difficult to discern the difference between invasive bacterial and viral infections.

Complications in children

Additional bacterial infections can lead to complications. In children, acute otitis media, affecting around 20%, is in the foreground [19], followed by bacterial sinusitis and pneumonia. High fever, lymph-node swelling and symptoms lasting more than two weeks are indications of complications.

Since pneumatization of the cranial air spaces only takes place with increasing age, infectious inflammations of the paranasal sinus cavity present themselves differently depending on age. Maxillary sinuses and ethmoidal cells appear early on, whereas in most children the sphenoidal sinus and frontal sinus generally only pneumatize during preschool or school age and only then can cause a problem.

4 Risk groups

Children and adolescents:
Time spent in communal facilities such as kindergartens and day care centers further increases the risk, and younger siblings at home are also affected. Infants still have insufficient immune protection. They are not only frequently affected, but also particularly at risk of developing complications such as pneumonia or bronchiolitis.

People with chronic heart or pulmonary diseases and older people: primarily responsible are a dysfunction of the immune system, a stronger tendency towards inflammatory responses and increasing infirmity (frailty) of the individuals [13]. Changes of the immune function cause a loss of protective immunity against infectious agents [20]. Furthermore, the activity of natural killer cells (NK cells) declines in healthy older people [21].

The environmental factors that can trigger a secondary immune dysfunction include medication, insufficient physical activity and malnutrition, as can be observed in most sick older people [22].

5 Differential diagnostics

Differential diagnostics are primarily performed to identify influenza. The course of primary infection with herpes virus in children is occasionally similar to a flu-like infection, as are infections with measles, rubella and varicella.

5.1 Influenza

While an uncomplicated respiratory tract infection rarely lasts longer than a week and the symptoms decline significantly after two to three days, the clinical picture of influenza extends from courses with few symptoms to severe toxic courses [23].

Characteristic: very sudden onset of high fever of more than 39 °C, chills, muscle pain (myalgia) and sweating (Fig. 4). While for older patients the start is often gradual, the complication rates are higher for this group of patients.

The symptoms last seven to fourteen days, although individual symptoms may still persist for weeks. Influenza can only be diagnosed with certainty by the direct detection of the virus from smears, or by means of antibody detection.

Complications:

• can occur at any age
• primarily affect persons with basic illnesses (chronic heart and pulmonary diseases, immunodeficiency).

Relatively often, influenza pneumonia occurs with bacterial superinfection (staphylococci, pneumococci arthritis, and Haemophilus influenzae).

Otitis media can also occur in children.

Contagion:

• shortly before the occurrence of the clinical symptom complex (within less than 24 hours)
• remaining for three to five days
• small children can shed viruses earlier and for a longer period of time than adults [23].

5.2 Bacterial infections

A laboratory chemical differentiation between viral and bacterial bronchitis is not required, because there would be no consequences in terms of treatment; nor is a leukocyte or CRP determination necessary, in general [24].

Sputum examination for acute bronchitis in otherwise healthy adults is not required, because primary antibiotic treatment is generally not indicated [25].

6.1 Wait and see

While therapeutical temporizing (“wait and see”) is broadly applied in the field of acute respiratory infections, it is nevertheless controversial, in part because the symptoms of an infection of the lower respiratory tract can persist for a very long time [26, 27]. Also, an acute respiratory tract infection can have a bacterial superinfection as a consequence, such as pneumonia. A “wait and see” strategy is therefore inadvisable.

6.2 Non-drug therapy

• a common treatment option for of uncomplicated respiratory tract infections

The measures include:

• Physical rest
• Sufficient amount of fluid intake, at least two liters per day (for older patients with heart and kidney insufficiency, an adjustment may be necessary, due to possible electrolyte fluctuations).
• Hypertonic or isotonic saline solutions as nasal rinses for rhinosinusitis and rhinitis. The liquefaction of the nasal secretion improves mucociliary clearance. An advantage appears to be confirmed for chronic rhinosinusitis [29].
• Steam inhalation (20 minutes at 43 °C water temperature) can lead to significant relief from symptoms. However, a Cochrane Review in 2013 was not able to establish any proven benefit [30].
• Nicotine avoidance (active and passive) primarily serves to prevent recurrence.
• Humidifying the air (particularly during the heating period).
• Antipyretic measures (calf compresses) for high-risk patients and very high body temperatures (>39 °C).

Infection prophylaxis: washing hands in order to avoid contact infections [31].

6.3 Medicinal treatment

6.3.1 Leitlinien

Guidelines provide recommendations for the medicinal treatment of acute respiratory tract infections, e.g.

• DEGAM guidelines (German College of General Practitioners and Family Physicians) [32]
• European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS Guideline) [33]
• Guidelines of the American College of Chest Physicians (ACCP) [34]

The guidelines

• evaluate the evidence of individual therapy options on the basis of available clinical studies
• provide pragmatic and practical expert recommendations.

These include the administration of palliative medication if the complaints greatly impair the patients [32]. Except for risk groups, the guidelines do not advise the use of antibiotics.

6.3.1 Antibiotics and antiviral drugs

Antibiotics

• are not advisable for the common cold
• cannot prevent complications; moreover, they contribute to bacterial resistance
• have little benefit for an uncomplicated respiratory tract infections (for patients who are ill for less than one week, as well as patients not suffering from heart or pulmonary diseases, without immunosuppression in their pre-history) [7].

Antibiotic treatment is indicated

• for severe courses (fever >39 °C, purulent nasal secretion, facial pain) over three to four consecutive days
• for biphasic courses, with renewed increase of symptoms after improvement of the common cold symptom complex

Amoxicillin continues to be the medication of choice, as well as for otitis media [37].

Antivirals

The use of antiviral drugs such as neuraminidase inhibitors is not recommended for low-risk patients, their use carries the risk of developing resistance.

Resistant microorganisms are very rapidly passed on and become a threat to small children and/or immune-compromised older family members.

Amantadine is only recommended as an emergency treatment after all other therapy options have failed [38].

6.3.2 EPs^® 7630 in the front line of therapy

The extract EPs^® 7630 is an active herbal substance obtained from the root of Pelargonium sidoides and manufactured by means of a special procedure. EPs^® 7630 contains polyphenols, proteins, purines, minerals, saccharides and 7‑hydroxycumarin derivatives in lower concentrations. As is typical for phytopharmaceuticals, some of the constituents of EPs^® 7630 are still unknown to this day; however, it has been demonstrated that only the total extract yields the optimal therapeutic effect [39].

6.3.2.1 Mechanism of action

EPs^® 7630 has a multifactorial mode of action (Fig. 5, 5a-5d).

Antiviral and cytoprotektive characteristics

As determined in in vitro and in animal models, this drug:

• Inhibits the proliferation of certain viruses that play a role in respiratory infections [40]
• Inhibits neuraminidase and hemagglutinins [41]
• Modulates the synthesis of interferons and proinflammatory cytokines [42-45]
• Has antioxidative characteristics [46]
• Inhibits leukocyte elastase [46]

Secretomotor and secretolytic characteristics

The recovery or promotion of mucociliary clearance is a decisive factor in the defense against respiratory infections.

EPs^® 7630 promotes this mechanism by:

• Stimulating the ciliary beat frequency of the respiratory epithelium [47]
• Significantly increasing secretory activity [48]

Antibacterial characteristics

EPs^® 7630 shows bacteriostatic properties towards different multi-resistant Staphylococcus aureus strains [49] as well as indirect antibacterial effects:

• Increases the adhesion of bacteria to dislodged epithelial cells of the respiratory tract mucous membrane [50]
• Inhibits the adhesion of bacteria to living epithelial cells of the respiratory tract mucous membrane [50]
• Stimulates phagocytosis and chemotaxis [51]
• Inhibits the internalization in epithelial cells of the mucous membrane [50]

6.3.2.2 Clinical data

Clinical trials on acute bronchitis

The Bronchitis Severity Score (BSS) has been used since 1996 to standardize the evaluation of the symptoms of acute bronchitis. As validation analyses show, the BSS measures the clinical situation very well and is therefore recommended as the criterion for the evaluation of therapeutic success in clinical trials [52a, 52b, 53].

In the indication acute bronchitis, EPs^® 7630 was tested in eight placebo-controlled double-blind trials including more than 2,600 patients. As a result, EPs^® 7630 proved to be a safe, well-tolerated and effective option for the treatment of acute bronchitis. The mean duration of bronchitis was shortened by two days [54].

Clinical trials on acute bronchitis in adults

In two trials [55, 56], the efficacy and safety of EPs^® 7630 drops (3x30/d) versus placebo in acute bronchitis were investigated. Adults who had been ill with acute bronchitis for 48 hours at most and whose BSS was at least five points were included. The primary test criterion was the change in the BSS on day seven.

After seven days, the BSS in the group of patients with active treatment dropped significantly faster than in the placebo group, and the duration of sickness of patients with active treatment was significantly shorter in both studies (Fig. 6). On average, patients from the active substance group could return to work about two days earlier than patients from the placebo group. With EPs^® 7630 tablet treatment, the BSS also fell significantly faster and had a higher clinical significance than placebo [54]. Along with another clinical trial [57], this trial moreover showed a pharmaco-economic advantage of EPs^® 7630 therapy.

Clinical trials on acute bronchitis in children and adolescents

Two trials specifically investigated the effects of EPs^® 7630 on children and adolescents between the ages of one and eighteen years suffering from acute bronchitis. The dosage depended on age [58, 59]. Up to day seven, a continuous decline of the mean BSS was observed with a significantly greater change in the active substance group than in the placebo group. Responder rates, defined as Total BSS < 3 points on day 7, were also significantly higher in the EPs^® 7630 group than in the placebo group (Fig. 7). Similar results were found in a dose-finding clinical trial with EPs^® 7630 tablets [60].

In an open safety trial with 602 children between the ages of one and five years with symptoms of acute bronchitis [61], changes in vital signs and laboratory parameters as well as adverse events were investigated under treatment with EPs^® 7630 drops and EPs^® 7630 syrup. The respiratory symptoms improved in both groups after seven days of treatment. Syrup for children and drops were comparable with regard to safety, tolerability and efficacy.

Clinical studies of acute sinusitis and tonsillopharyngitis

The central test criterion in sinusitis trials is the Sinusitis Severity Score (SSS), composed of the symptoms “headache ”, “pain in the upper jaw”, “worsening of the pain in the upper jaw when leaning forward”, “congested nose”, “purulent nose secretion”, and “purulent discharge in the middle nose passage”. These symptoms are evaluated on a scale of 0 (not present) to four (very severe) [62, 63].

Trial on adult patients with acute rhinosinusitis: evaluation of the efficacy and tolerability of EPs^® 7630 compared to placebo. The difference in mean reduction of the Sinusitis Severity Score (SSS) was statistically significant after seven days of treatment (Fig. 8). This difference increases with increasing duration of treatment and after 21 days, it had more than doubled [62]. These findings were confirmed by the results of an earlier trial [63], in which children up to the age of twelve years were investigated as a subgroup.

There are also trials on the indication tonsillitis e.g. acute tonsillopharyngitis in children [64] and acute tonsillitis/ acute exacerbation of chronic tonsillitis in children and adults [65]. For children with acute tonsillopharyngitis, EPs^® 7630 was better than placebo with respect to the reduction of the Tonsillitis Severity Score (TSS) after four days of treatment. The patients in the EPs^® 7630 group were also able to attend school again earlier [66].

Reviews and meta-analyses

Data from several trials are pooled in meta-analyses in order to obtain the best possible analysis of the efficacy of a certain therapy option through using a large number of patients.

Randomized clinical trials of EPs^® 7630 for acute bronchitis were analyzed in comparison to placebo or standard therapy [67]. All results suggested the good efficacy of EPs^® 7630 for acute bronchitis. The use of EPs^® 7630 to treat acute respiratory infections was investigated in a meta-analysis by the Cochrane Collaboration [68]. The analysis came to the conclusion that EPs^® 7630 can alleviate the symptoms in adults and children with acute bronchitis and in adults with acute rhinosinusitis or the common cold. An additional meta-analysis [69] confirmed these results.

In the most recent analysis from 2016 [66], the authors concluded that: “EPs^® 7630 is an effective, safe and well-tolerated herbal drug product for the treatment of acute respiratory tract infections such as acute bronchitis, acute rhinosinusitis and acute tonsillopharyngitis in children, teenagers and adults.”

6.3.3.3 Safety profile

The favorable clinical safety profile of EPs^® 7630 is supported by evidence from clinical trials and noninterventional studies [70]. In nineteen double-blind, placebo-controlled trials, the type and incidence of undesired events with EPs^® 7630 were similar to those in patients treated with placebo. Only for gastrointestinal complaints and nosebleeds was the event rate somewhat higher than with placebo (differences of 2.9% and 0.6%, respectively).

The incidence rate of adverse events associated with the liver was 0.48% for EPs^® 7630 and for placebo. Furthermore, the analysis of the available ASAT, ALAT and γ-GT values showed no statistically relevant differences; thus no indications of hepatotoxic effects within the scope of routine administration were found.

The results of the clinical trials were fully supported by the data from the post-marketing surveillance study. There is an extremely low rate of reporting of suspected cases of undesirable pharmaceutical effects. EPs^® 7630 is therefore suitable as a well-tolerated herbal drug product for the treatment of acute respiratory tract infections in adults and children.

6.3.4 Other phytopharmaceuticals

Other phytopharmaceuticals are also regularly used.
These include myrtle, eucalyptus oil and cineole as well as ivy, thyme, mustard oil glycoside and combination preparations. Meanwhile, there are some positive results for some of these from trials that have been summarized in different meta-analyses [71-77]. For instance, in a trial with 371 subjects between the ages of 18 and 75 years, the frequency of the common cold was shown to be significantly reduced by the consumption of a combination drug product consisting of horseradish root (armoraciae rusticanae radix) and nasturtium (tropaeoli majoris herba), compared to placebo [75].

Substances containing ivy and thyme can alleviate the urge to cough and facilitate expectoration of thick mucus. Saponins in ivy promote expectoration, and thyme extracts can stimulate the activity of the secretory cells in the bronchi. Both extracts can, moreover, act to promote relaxation, which possibly can be helpful for children with spastic bronchitis. A meta-analysis of the data from ten studies confirmed the effectiveness; after seven to ten days, symptoms such as coughing were significantly reduced and the only placebo-controlled trial showed a significant advantage in the active substance group compared to the control group [73].

Cineol, myrtle, as well as BNO-101 and BNO 1016 and combinations composed of five plant extracts (gentian, cowslip, sorrel, elder and vervain) were also found to alleviate the symptoms of acute viral rhinosinusitis in clinical studies compared to placebo. In a myrtle study on patients with acute sinusitis, the patients in the myrtle group recovered faster than those in the placebo group [76].

A comparative trial showed no significant differences between BNO-101 and N-acetylcysteine. The authors certify that the substance has a favorable risk-benefit relationship comparable to the placebo with regard to the incidence of undesirable effects. Attention should be paid to the fact that the onset of the effect only occurs after four to seven days. With BNO 1016, patients with acute rhinosinusitis showed an improvement in symptom score two days earlier than placebo patients [77].

The data for drug products containing Echinacea are inconsistent and its application is therefore currently not recommended.

Recommendations in the phytomedicines field are generally difficult, due to the different compositions and the extremely non-uniform study population. The practical experience with phytopharmaceuticals is predominately good to excellent, however, so that their use for symptom control is recommended.

6.3.5 Symptomatic supportive therapy

If medicinal treatment is desired by the patients, supportive therapy is often in focus for the relief of complaints, besides first-line therapy.

6.3.5.1 Coughing

Apart from abstention from noxious substances (smoking withdrawal) and non-medicinal treatment options (cough drops, teas for the treatment of coughs, warm compresses and inhalation), in principle, two groups of medications come into play: antitussives and expectorants.

Centrally acting antitussives to inhibit the coughing reflex:

• Codeine
• Dextromethorphan
• Noscapine
• Pentoxyverine
• Herbal antitussives (ribwort, thyme, drosera, edelweiss)

The DEGAM guidelines recommend that acute coughing in the framework of a respiratory infection should only be treated with antitussives in exceptional cases, since no adequate data are available [32].

Expectorants to increase the secretion volume (secretolytics) and reduce viscosity (mucolytics) to alleviate the irritation of the coughing receptors:

• Ambroxol
• Cineole
• Glyceryl guaiacolate
• Potassium iodide
• Acetylcysteine
• Herbal expectorants (anise, myrtle, peppermint. eucalyptus, thyme, ivy, primrose, ribwort, combinations)

Furthermore, despite frequent prescription, there is no sufficient evidence for using expectorants to treat acute coughs and colds [78]. Only the treatment of chronic bronchitis with acetylcysteine was shown in a review to reduce exacerbation and relieved symptoms [79].

6.3.5.2 Nasal congestion

A congested nose is expressed by aggravated nasal respiration and a feeling of pressure in the head, amongst other things. These complaints become worse when lying down. The following are used for symptomatic treatment, among others:

• Alpha-sympathomimetic drugs (xylometazoline, oxymetazoline, tramazoline)
• NaCI solution (hypertonic or isotonic)
• Local corticoids

The administration of decongestant alpha-sympathomimetic drugs has only a short-term effect; repeated administration over seven days leads to no relief of symptoms and poses a danger of atrophic rhinitis (rebound-effect). Application beyond the period of a week is therefore not recommended [80].

Owing to a lack of sufficient data, Cochrane analyses on the effectiveness of NaCl solutions [81] and local corticoids [82] do not result in recommendations.

6.3.5.3 Headache and myalgia

Analgesics, primarily paracetamol and the non-steroidal antiphlogistics (NSAIDs such as ibuprofen, diclofenac, naproxen and COX-2 inhibitors) are frequently used for the symptomatic relief of headache and myalgia. They have analgesic, anti-inflammatory and antipyretic properties.

The Cochrane analysis of paracetamol yielded insufficient data for headaches and myalgia [83]. This is also the case for non-steroidal anti-inflammatory drugs [84]. The recommendation here is to weigh the slight benefit against the risks (stomach and gastric ulcers, cardiovascular diseases and kidney disease on longer term and regular consumption). The same applies to acetylsalicylic acid, which, moreover, is not suitable for children.

6.3.5.4 Sore throat

Apart from the systemic analgesics described above, additional medication can be prescribed or recommended for a sore throat:

• Topical local anesthetics
• Topical disinfectants
• Phytopharmaceuticals

Topical local anesthetics such as oxybuprocaine, lidocaine or ambroxol are applied locally in the form of sprays, gargle solutions and lozenges, as well as topical disinfectants (such as chlorqinaldol, dichlorobenzylalcohol, iodine or chlorhexidine). They work in part as local anesthetics. Their effectiveness against bacteria is indisputable, but their benefit for viral infections is a matter of debate.

Herbal medicinal products against sore throats and pharyngitis include local anesthetic drug products with cloves and sage, soothing drug products such as mallow and Islandic moss, as well as immuno-stimulating Echinacea preparations. Many bronchial lozenges contain diverse herbal constituents.

7 Summary for practice

• Acute respiratory infections are among the most frequent reasons for visits to the family physician or pediatrician.
• Important therapeutic goals are the reduction of the duration of sickness and the avoidance of complications.
• Since such infections are predominantly viral, antibiotic treatment is of little benefit and not generally applicable.
• Phytopharmaceuticals are a good alternative. The data for first-line therapy are altogether mixed; currently the best results are seen for EPs^® 7630.
• Apart from first-line therapy, symptomatic supportive therapy for the relief of complaints is recommended.

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