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S Afr Fam Pract
ISSN 2078-6190 EISSN 2078-6204

REVIEW

Introduction

The common cold, otherwise known as a self-limiting upper

respiratory tract infection, is caused by the rhinovirus,

coronavirus or the adenovirus1. Symptoms like sneezing, nasal

congestion, coughing, sore throat and a low grade fever are

often experienced during the winter season2. A person may be

contagious after being infected with the virus, but before they

present with symptoms, and until after all the symptoms have

subsided3. The viruses in question are airborne and spread

quickly via hand-to-hand contact, or via the inhalation of

airborne droplets from sneezing and coughing1.

After the virus enters the nasal cavity it damages the ciliated

cells resulting in the release of inflammatory mediators and

causing inflammation of the nasal tissue lining1. The increase

in permeability of the capillary cell walls results in oedema.

Oedema is responsible for symptoms like sneezing and nasal

congestion1,3. A postnasal drip may develop and is responsible for

spreading the virus, which leads to a sore throat and coughing1.

Common colds are self-limiting and resolve within 7-10 days

without the use of antibiotics. However, some people may

develop a secondary bacterial infection2.

The common cold is often confused with the flu. However, the

flu is a viral illness that is caused by the influenza virus and has a

high mortality and hospitalization rate4. Influenza can occur all

year round but is seen more from May through winter. Due to the

constant evolution of the influenza strains there a higher fatality
rate associated with the virus1.

The influenza virus is transmitted via air droplets when a person
comes into close contact with an infected person or via self-
infection when a person comes into direct contact with an
infected person or object5.

Table 1: Types of influenza strains and their differences1.

Virus Strain: Influenza A Influenza B

Who can become
infected:

Animals and Humans Humans

Severity of
infection:

Causes pandemics,
like swine flu and
bird flu.

Less severe than
Influenza A.

A rapid onset of fever, headaches, myalgia, body aches and
pains, sore throat and rhinitis (runny nose) are associated with

Abstract

The common cold and flu are two very different viruses that share very similar symptoms. The common cold is a self-limiting
upper respiratory tract infection and it is caused by the rhinovirus, coronavirus or the adenovirus. It usually resolves within 7-10
days. The flu is caused by the influenza virus and usually presents with headaches, myalgia, fever and body aches. There is no
place for antibiotic usage in colds and flu and there is no clinical evidence which suggests that using antibiotics alters the course
of the disease or prevents secondary infection. Treatment is mainly symptomatic and includes many over the counter medicines,
antivirals and herbal treatment.

Keywords: colds, flu, rhinovirus, coronavirus, adenovirus, influenza, upper respiratory tract infections, herbal medicine, antivirals,
over-the-counter medicine

South African Family Practice 2017; 59(3):5-12

Open Access article distributed under the terms of the
Creative Commons License [CC BY-NC-ND 4.0]
http://creativecommons.org/licenses/by-nc-nd/4.0

Colds and flu – an overview of the management
Halima Ismail,1 Natalie Schellack2*

1Academic Intern, School of Pharmacy, Faculty of Health Sciences, Sefako Makgatho Health Sciences University
2Associate Professor, School of Pharmacy, Faculty of Health Sciences, Sefako Makgatho Health Sciences University
*Corresponding author, email: natalie.schellack@smu.ac.za

Hand-to-hand contact: Self-infection by touching a
person or object that is infected with the virus.

Droplet transmisssion: Inhalation of airborne
droplets.

Close contact with infected persons: Infection by
disposition of large air droplets from sneezing.

Figure 1: Transmission of viruses that cause colds2.

S Afr Fam Pract 2017;59(3):5-126

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the flu. These symptoms generally last for 4-5 days and then
disappear, however a person may experience coughing and
malaise for more than 14 days1, 2. Influenza-like illness (ILI) is an
acute respiratory infection that presents with a fever greater than
38˚C, coughing or pharyngitis. The diagnosis of influenza-like
illness is rarely based on the patient’s clinical picture. Laboratory
diagnosis usually includes6:

• Virus isolation in cell culture

• A polymerase chain reaction (PCR) test

• Antigen detection.

Management of common colds and flu

Pharmacotherapy is directed at alleviating associated symptoms.
Antibiotics are often prescribed erroneously, and in the absence
of a secondary bacterial infection. Antibiotics should only be
administered when a bacterial infection has been identified, and
should not be used as a preventative measure. The following
measures can be used to either prevent or treat the symptoms of
a common cold and the flu (each of these recommendations will
be discussed separately) 1, 5:

• A flu vaccine is recommended by the Centers for Disease
Control and Prevention (CDC), in the United States of America,
as a preventative measure against the acquisition of the
influenza virus

• Selected over-the-counter (OTC) products contain a
combination of active ingredients which help with
symptomatic relief

• Drinking plenty of fluids, especially water: Water has been
shown to be the best fluid with which to lubricate the mucous
membranes

• Vitamins and minerals, e.g. vitamin C and zinc sulphate

• Antiviral drugs, e.g. neuraminidase inhibitors (zanamivir
and oseltamivir), as well as N-methyl D-aspartate receptor
antagonists (amantadine and rimantadine)

• Other, such as orally-inhaled anticholinergics, inhaled
corticosteroids, herbal solutions and nonsteroidal anti-
inflammatory drugs (NSAIDs).

Vitamins and Minerals

The prophylactic use of vitamin C has been shown to reduce
the risk of developing a cold or flu in certain populations, e.g.
athletes, with a reduction of approximately 6% in the disease
duration. However, the evidence that supports the use of vitamin
C in high dosages to reduce the severity of a cold or flu is lacking
and inconclusive.

Zinc may inhibit viral growth, and could possibly reduce the
duration of cold symptoms. However, not enough high-quality
trials support the routine and high-dosage use of zinc in
preventing a cold or flu. Some reports have been lodged with the
US Food and Drug Administration (FDA) that nasal preparations
containing zinc may cause loss of smell. Zinc may also reduce the
absorption of certain antibiotics. Food containing calcium and
phosphorus can impair the absorption of zinc7.

Importance of Hydration

Fluid (especially water) helps to lubricate the mucous membranes
of patients suffering from the common cold or influenza. However,
some literature contradicts this by suggesting that the provision
of extra fluid to patients with acute respiratory conditions may
cause hyponatraemia and fluid overload, because of antidiuretic
hormone. This hormone is released in adults and children with
lower respiratory tract infections and causes water reabsorption
from the renal collecting duct. The combination of the increased
production of the antidiuretic hormone and extra fluid may
lead to fluid overload. Research has not clearly illustrated this in
upper respiratory infections yet and water hydration still remains
of importance in common colds and flu1,8, 9.

Other strategies used to treat the common cold and flu

Anticholinergic agents, such as inhaled ipratropium bromide,
may be used to treat a cough caused by the common cold. Nasal
preparations have shown some efficacy in reducing rhinorrhoea
and sneezing. Inhaled corticosteroids can be used to reduce the
swelling and inflammation of the nasal mucosa, but have not
been shown to provide any benefit in patients diagnosed with
a common cold1.

Conflicting evidence has emerged about the use of nasal
irrigations. Nasal irrigations constitute a mechanical intervention.
It is not classified as a decongestant and does not improve
ciliary function. Studies have shown that nasal preparations that
contain a certain preservative, namely benzalkonium chloride,
may worsen symptoms and infections. Nasal washes that contain
a lot of fluid and minimal salt can be used to remove mucus from
the nose, removing bacterial products, and improving sinonasal
function. Nasal irrigations can be used prior to the administration
of topical therapies to ensure true sinus distribution1, 10.

There are several different OTC medications that can be used to
alleviate pain and fever associated with the common cold and
flu. The typical active ingredients are aspirin, paracetamol and
caffeine. Aspirin, however, is contraindicated in children who
have a viral infection as they are at risk of developing Reye’s
syndrome1, 2.

The use of codeine or hydrocodone as a cough suppressant has
not been found to be any more beneficial than a placebo1.

Herbal products and supplements include substances like
Echinacea, Chinese herbal cold and allergy products, elderberry
extracts, Andrographis paniculata, Pelargonium sidoides and
Acanthopanax senticosus1, 11.

Probiotics were more effective than placebo in reducing the
number of episodes as well as the rate of episodes of upper
respiratory tract infections11.

The flu or influenza vaccine

Influenza vaccines then provoke an immune response to the
antigen found on the surfaces of the viruses. Antigenic drift can
occur in the viruses, causing resistance to the vaccine12. It is for
this reason that recommendations are based on the World Health

Colds and flu – an overview of the management 7

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Organization’s accredited regional laboratories, and changes are

made to the composition, in terms of strains of influenza every

year13, 14. This is also the reason why the vaccine that is released in

September every year in the Northern Hemisphere is not always

exactly the same as that released in February in the Southern

Hemisphere.

Antibodies usually develop within two weeks of the vaccine

being administered. A peak in immunity occurs four to six weeks

after vaccination, which then gradually wanes again. It therefore

does not convey lasting immunity against the influenza virus.

Immunisation reduces the likelihood of the flu developing in

healthy adults by approximately 70-90%14. If a family member

or house mate has already developed the flu, vaccination of

other members, within 36-48, hours will still provide effective

protection against the virus14.

Table 3: List of individuals who would require the flu vaccine as
a matter of priority1.

Individuals that require the vaccine as a matter of priority

Pregnant women, and women who are planning to fall
pregnant during winter

Patients younger than 18 years of age on chronic aspirin
therapy

HIV infected patients (CD4 cell count >100 cells/uL).

Patients who suffer from any other disease which leaves
them immune compromised

People who suffer from an underlying medical condition, e.g.
diabetes mellitus, COPD, heart disease

People older than 65 years of age, or infants between 6-49
months of age.

People staying in old age homes, frail care facilities and
rehabilitation centres

Healthcare workers who have direct contact with patients on
a daily basis

Patients who are on glucocorticosteroid therapy for long
periods of time

In the southern hemisphere, it is recommended that the vaccine

be given in April; however, it can be given throughout the winter

season. Figure 2 below depicts the adverse effects that are

associated with the flu vaccine1.

Combination Products used for common colds and flu

Antitussive agents (cough suppressants)

Antitussive agents should only be given for a non-productive,

dry, irritating cough (refer to Table IV). Care should be taken

when giving antitussive agents as the coughing mechanism

serves as a protective function of the body. Coughing clears the

throat and the lower respiratory tract of foreign particles and

mucus. Coughing that occurs as a result of bronchoconstriction

and bronchospasm (coughing in asthma and COPD patients)

should be treated with bronchodilators. Coughing that is caused

by a lower respiratory tract infection should be managed with

appropriate antimicrobial agents.

Certain classes of drugs are able to supress the coughing

mechanism, such as opioid analgesics and opioid derivatives

(codeine phosphate, methadone, etc.)1,13.

Table 2: Herbal products and supplements1, 11.

Herbal product Evidence supporting the use of the medicine Adverse effects

Echinacea No evidence supports the use of this product in
the treatment of colds and flu.

People who are allergic to Echinacea develop
erythema nodosum, which features tender, red
nodules under the skin

Chinese herbal cold and allergy products No evidence supports the use of this product in
colds and flu

These products also pose the risk of renal
damage and cancer as they contain aristolochic
acid.

Elderberry extracts Some evidence supports the use of these
extracts in shortening the duration of flu
symptoms.
However this has yet to be confirmed by bigger
studies.

These extracts are unsafe when the leaves, stems,
unripe fruit or uncooked fruit is consumed.

Pelargonium sidoides (commonly known
as African geranium) and Acanthopanax
senticosus

Literature has confirmed a reduction in the
duration of 10 different flu symptoms.

There are isolated reports of liver toxicity;
however, no causative relationship has been
linked to the herb itself.

Flu-like symptoms, which develop with 2-24 hours
after vaccination

Allergic reactions in people who have an egg allergy

Soreness and tenderness at the site of the injection

Figure 2: Adverse effects of flu vaccines12, 13, 14.

Please Note: Individuals with allergies to eggs or
chicken proteins should not recieve vaccines that are

produced via egg-based culturing techniques.

S Afr Fam Pract 2017;59(3):5-128

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Table 4: Over-the-counter medicine for the treatment of colds and flu1, 13.
Preparation Active ingredient Indication
Topical decongestants
Illiadin® Oxymetazoline (0.100 mg/ml) Short-term symptomatic relief of nasal congestion
Drixine® Oxymetazoline (0.5 mg/ml) Short-term symptomatic relief of nasal congestion
Nazene® Adult Nasal Metered Spray Oxymetazoline (0.5 mg/ml) Short-term symptomatic relief of nasal congestion
Otrivin® Xylometazoline (1 mg/ml) Short-term symptomatic relief of nasal congestion
Sinutab® Nasal Spray Xylometazoline (1 mg/ml) Short-term symptomatic relief of nasal congestion
Vibrocil-S® Phenylephrine and dimethindene (250 mg/100 g) Short-term symptomatic relief of nasal congestion
Topical Corticosteroids
Avamys® Fluticasone furoate (50 µg/spray) Maintenance therapy for allergic rhinitis
Beclate Aquanase® Beclomethasone dipropionate (50 µg/spray) Maintenance therapy for allergic rhinitis
Beconase® Beclomethasone dipropionate (50 µg/spray) Maintenance therapy for allergic rhinitis
Clenil® Aq Nasal Spray Beclomethasone dipropionate (50 µg/spray) Maintenance therapy for allergic rhinitis
Flomist® Fluticasone propionate (50 µg/spray) Maintenance therapy for allergic rhinitis
Flonase® Fluticasone propionate (50 µg/spray) Maintenance therapy for allergic rhinitis
Nexomist® Mometasone furoate (50 µg) Maintenance therapy for allergic rhinitis
Rinelon® Mometasone furoate (50 µg) Maintenance therapy for allergic rhinitis
Topical antihistamines/anti-allergic agents
Rhinolast® Azelastine (0.14 mg/spray) Short-term intermittent allergic rhinitis
Sinumax Allergy Nasal Spray® Levocabastine (0.5 mg/ml) Short-term intermittent allergic rhinits
Vividrin® Cromoglicic acid (2.6 mg/spray) Intermittent or persistant allergic rhinitis
Other nasal preparations
Mistabron® Mesna (50 mg/ml) Nasal obstruction owing to thick secretions
Systemic nasal decongestants with antihistamines
Actifed® Pseudoephedrine HCl (30 mg) Triprolidine HCl (1.25 mg) Systemic decongestion of nasal mucosa and

sinuses associated with colds and flu
Betafed Be-Tabs® Pseudoephedrine HCl (30 mg) Triprolidine HCl (1.25 mg) Systemic decongestion of nasal mucosa and

sinuses associated with colds and flu
Demazin Syrup® Phenylephrine HCl (2.5 mg/5 ml) Chlorpheniramine

(1.25 mg/5 ml)
Systemic decongestion of nasal mucosa and
sinuses associated with colds and flu

Demazin NS® Pseudoephedrine sulphate (120 mg) Loratidine (5 mg) Systemic decongestion of nasal mucosa and
sinuses associated with colds and flu

Systemic decongestant and/or analgesic and/or antihistamine combinations
Efferflu C ® Cold and Flu Paracetamol (500 mg)

Chlorphenamine maleate (2 mg) Vitamin C (250 mg)
Symptomatic relief of colds and flu

Benylin® for colds Pseudoephedrine HCl (30 mg) Ibuprofen (200 mg) Symptomatic relief of colds and flu
Nurofen® Cold and Flu Ibuprofen (200 mg) Pseudoephedrine HCl (30 mg) Symptomatic relief of colds and flu
Sinuclear® Paracetamol (325 mg) Phenylpropanolamine HCl (18 mg) Symptomatic relief of colds and flu
Sinugesic® Paracetamol (500 mg) Pseudoephedrine HCl (30 mg) Symptomatic relief of colds and flu
Sinumax® Paracetamol (500 mg) Pseudoephedrine HCl (30 mg) Symptomatic relief of colds and flu
Sinustat® Paracetamol (325 mg) Phenylpropanolamine HCl (18 mg) Symptomatic relief of colds and flu
Sudafed® Sinus Pain Paracetamol (500 mg) Pseudoephedrine HCl (60 mg) Symptomatic relief of colds and flu
Cough preparations
Mucolytic
Solmucol® N-Acetylcysteine To reduce viscosity of secretions
Mucatak®
Amuco 200®
ACC200®
Betaphlem® Carbocisteine To reduce viscosity of secretions
Bronchette®

Flemex®
Lessmusec®
Mucospect®

Bisolvon® Bromhexine HCl To reduce viscosity of secretions
Expectorants

Benylin Wet Cough Menthol® Guaifenesin Cough alleviation
Cough suppressants
Benylin® Dry Cough Dextromethorphan Symptomatic relief of a non-productive cough
Dilinct® Dry Cough
Nitepax® Noscapine
Pholtex® Forte Pholcodine
Pholtex Linctus® Pholcodine 15 mg/10ml Phenyltoloxamine (10 mg/10 ml)

Whatever the reason,
whatever the season

S4 AVAMYS Nasal Spray (Suspension). Reg. No.: 41/21.5.1/0968. Each 50 µl spray contains 27,5 µg of fluticasone furoate. Preservative: Benzalkonium
chloride 0,015 % m/m. PHARMACOLOGICAL CLASSIFICATION: A.21.5.1 Corticosteroids and analogues.

GlaxoSmithKline South Africa (Pty) Ltd, (Co. Reg. No.: 1948/030135/07), 39 Hawkins Avenue, Epping Industria 1, Cape Town, 7460. Tel: +27 11 745 6000.
Fax +27 11 745 7000. Marketed by Aspen Pharmacare, Building 12, Healthcare Park, Woodlands Drive, Woodmead, 2191. All adverse events should
be reported by calling the Aspen Medical Hotline number or directly to GlaxoSmithKline on +27 11 745 6000. For full prescribing information refer to the
package insert approved by the medicines regulatory authority. A19340 05/15 ZAF/FF/0001/15a

17853 Avamys advert A4.indd 1 02/06/2015 10:03 am

S Afr Fam Pract 2017;59(3):5-1210

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Antihistamines

The first-generation antihistamines, such as chlorpheniramine,

brompheniramine and promethazine, are used to reduce certain

symptoms of a cold, like rhinitis and sneezing. This is due to

the anticholinergic effects of these drugs. Some of the first-

generation antihistamines are also used for their antitussive

action and are combined in cold medicines to help patients sleep.

Literature has stated that antihistamines used alone are of very

little benefit in treating symptoms of the common cold and flu,

but they do offer symptomatic relief when used in combination

with decongestants and antitussive agents5.

Please note: In 2007 promethazine-containing medicines were

contraindicated in children under the age of two years15.

Expectorants and mucolytic agents

Expectorants and mucolytic drugs are used to alter the viscosity

of mucous and bronchial secretions, thereby making it easier

to cough up sputum1, 16. There are two ways of achieving this

through pharmacological action:

• By using expectorants to increase the volume of bronchial

secretions and reduce the viscosity of these secretions.

Guaiphenesin, sodium citrate and ammonium chloride are

examples of expectorants. For obvious reasons, the use of

cough mixtures containing an expectorant, as well as an

antitussive agent, or combined with an antihistamine, should

rather be avoided.

• By using mucolytic agents, which act by altering the structure

of mucus, thus resulting in a low mucus viscosity. Examples

are: carbocisteine, bromhexine and N-acetylcysteine. Dornase

alfa (recombinant human DNase) is used in patients with cystic

fibrosis.

Non-pharmacological methods, like maiming a good fluid

hydration status and inhaling steam, can also reduce the viscosity

of mucous secretions.

Oral decongestants:

Oral sympathomimetic, systemic decongestants, like

pseudoephedrine phenylpropanolamine and phenylephrine

are now mainly available in combination in South Africa5. Oral

decongestants should only be used for a short period of time

and as symptomatic relief for acute coryza, as part of flu and

influenza. Topical agents are preferred as they have reduced

systemic side-effects1. Clear warnings should be given to

patients about the use of oral decongestants with alcohol or

certain drugs like sedatives13, 17.

Nasal decongestants:

Nasal congestion, a result of vasodilation and oedema of the nasal

mucosa, can be alleviated using alpha-1 adrenergic agonists

topically (nasal sprays) or orally. These topical decongestants

are actually vasoconstrictors and compared to a placebo have

shown a reduction in airway resistance1, 5, 13, 17.

Antiviral Agents

Neuraminidase inhibitors

Zanamivir and oseltamivir are currently available. These drugs

are registered for the prophylaxis of the influenza A and B virus,

and should be used within the first 24 hours of the onset of the

symptoms. These agents act by inhibiting the enzyme involved

in viral replication, neuraminidase. Important information

regarding the use of these agents is listed in Figure 3 below1, 18:

Table 5: Important differences between zanamivir and oseltamivir1, 18.

Zanamivir Oseltamivir

Administered through an inhaler. Available as a suspension and a
capsule.
It has minor side effects like
nausea and vomiting.

May provide a challenge to older
patients and patients with a lung
disorder.

Dosage adjustments in patients
with renal impairment.

N-methyl D-aspartate receptor antagonists

Amantadine is an antiviral drug that is commonly associated

with the treatment of Parkinson’s disease. It is however also used

in the prevention and treatment of influenza A. Amantadine acts

by increasing the amount of dopamine from the nigrostriatal

Their use in avian ('bird') flu has not been fully established.

They can reduce the transmission of the virus.

If used within the first four days of the symptoms
presenting, they can prevent complications of the virus.

They only reduce flu symptoms by one day and this
reduction occurs only if the agent was started within 48
hours of the symptoms presenting.

They are used to prevent/treat Influenza A and B.

Oseltamivir should be intitated in indviduals who are at a
higher risk of contracting influenza and complications of
influenza like immune compromised patients.

Reports of fatal neuropsychiatric conditions have been
filed.

Oseltamivir has been approved in preventing the virus
from occurring in patients older than one year.

Figure 3: important information regarding the use of oseltamivir and
zanamivir1, 18.

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pathway and inhibits the reuptake of dopamine by the neurons.
Amantadine is currently not recommended for treatment or use
as an antiviral agent as there is wide-spread resistance to the
drug1, 13, 18.

If the drug is being used for minor sensitive strains the following
should be noted:

• Initiation of amantadine should occur within 2 days after
contracting influenza A as it may reduce the duration of the
disease.

• It cannot be used against influenza B.

• There is no literature which supports the drug preventing
complication of influenza A.

Conclusion

Antibiotics should never be used to treat the common cold
or flu, unless there is a secondary bacterial infection. There is
insufficient evidence in the literature to supports the use of OTC
producrs for the prevention of these viral infections; however,
vitamin C and zinc can be used as prophylaxis. Receiving the
influenza vaccine may reduce the risk of acquiring seasonal
influenza. Treatment is symptomatic; however, the use of many of
the OTC medicines is not supported by literature. Certain herbal
remedies like P. sidoides extract, A. paniculata and elderberry may
be effective, although a person should always read the safety
profile of these remedies first. Codeine and antihistamines may
be used in combination therapies to treat coughs and other cold
symptoms. Medicines, such as paracetamol and other NSAIDs,
may be used to manage pain and fever in adults. Antivirals, such
as the neuraminidase inhibitors, can be used in the prevention
and treatment of both influenza A and B.

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