upper respiratory infections
DESCRIPTION
Nathan Cleveland, MD, MSTRANSCRIPT
UPPERRESPIRATORYINFECTIONS
EVIDENCE-BASED MANAGMENT
NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 3 OCTOBER 2012
URIs
TITLE
TRIVIA
INTRO
GOALS
EBM
CASE
URI
URI PROBLEM
EVIDENCE-BASED
MANAGEMENT
URIsRIGHT THING
EVIDENCE-BASED
MANAGEMENT
TITLE
TRIVIA
INTRO
GOALS
EBM
CASE
URI
URI PROBLEM
URIs EVIDENCE-BASED
MANAGEMENT
4 RULES OF EMRULE #1 – Determine sick vs not-sickRULE #2 – Vitals are vitalRULE #3 – Risk stratify everybody
PATIENT
LR HR
CC
LR
HR 43
21
RIGHT THING
TITLE
TRIVIA
INTRO
GOALS
EBM
CASE
URI
URI PROBLEM
URIs EVIDENCE-BASED
MANAGEMENT
4 RULES OF EMRULE #1 – Determine sick vs not-sickRULE #2 – Vitals are vitalRULE #3 – Risk stratify everybodyRULE #4 – Go Early
AggressiveSymptomTreatment
RIGHT THING
TITLE
TRIVIA
INTRO
GOALS
EBM
CASE
URI
URI PROBLEM
URIsTRIVIA
EVIDENCE-BASED
MANAGEMENT
EBM PRINCIPLE
Reflexive care requires up-front knowledge of
the current best available evidence.
RIGHT THING
TRIVIA
INTRO
GOALS
EBM
CASE
URI
URI PROBLEM
URIsEBM FOR URI
EVIDENCE-BASED
MANAGEMENT
GOALS
1. The URI problem2. Abx management of:• Otitis media• Sinusitis• Pharyngitis• Bronchitis
TRIVIA
RIGHT THING
TRIVIA
GOALS
EBM
CASE
URI
URI PROBLEM
URIs EVIDENCE-BASED
MANAGEMENT
GOALS
3. Recommendations4. Attending trivia
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
EBM
CASE
URI
URI PROBLEM
URIsTRIVIA
EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
Four attendings are Eagle Scouts. Name any two:
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
EBM
URI
URI PROBLEM
URIs EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
DAVID OBERT, D.O., JOSHUA PARKER, M.D., MATT HORBAL,
M.D., JEREMY BAIRD, D.O.
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
EBM
URI
URI PROBLEM
URIsOTITIS
EVIDENCE-BASED
MANAGEMENT
DEFINING URI
NASAL CONGESTION
FEVER / CHILLS
SORE THROAT
SINUS PRESSURERUNNY NOSE
COUGH
EARACHE
URI
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
URI
URI PROBLEM
URIs EVIDENCE-BASED
MANAGEMENT
NON-EBM PRINCIPLE
The more systems involved in an illness, the more likely that illness is
caused by a virus.
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
URI
URI PROBLEM
URIs EVIDENCE-BASED
MANAGEMENT
ETIOLOGY OF URI
• Very difficulty to study• Potential bacteria = 7%
J Clin Micro. 1998;36(2):539-42
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
URI
URI PROBLEM
URIs EVIDENCE-BASED
MANAGEMENT
DEFINING URIThe “common cold”• Nearly always viral
• More than 200 subtypes
Sexton DJ, McClain MT. The common cold in adults: Diagnosis and clinical features. UpToDate. http://www.uptodate.com.hsl-ezproxy.ucdenver.edu. Accessed 9/24/2012.
Rhino Echo Paramyxo Entero
Adeno Coxsackie
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
URI
URI PROBLEM
URIs EVIDENCE-BASED
MANAGEMENT
THE URI PROBLEM• Most common illness• 500 million / year (US)• Incidence: 2-3/adult/year• Direct cost: $17 billion• Indirect cost: $22.5 billion• Common CC in EDs / UCCs
Kirkpatrick GL. The common cold. Prim Care. 1996;23(4):657
Fendrick AM, Monto AS, Nightengale B, Sarnes M. The economic burden of non-influenza-related viral respiratory tract infection in the United States. Arch Intern Med. 2003;163(4):487.
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
THE URI PROBLEM
Mainous AG 3rd. Hueston WJ. Clark JR. Antibiotics and upper respiratory infection: Do some folks think there is a cure for the common cold? J of Fam Pract. 1996;42(4):357-61.
other
↑
• Doctor visit = antibiotics
• 60% are prescribed antibiotic
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
THE URI PROBLEM
Gonzales R, Bartlett JG, et al. Principles of Appropriate Antibiotic Use for Treatment of Nonspecific Upper Respiratory Tract Infections in Adults: Background Intern Med.
2001;134:490-494.
other
↑
• 2nd leading dx for Abx
• 10-20% all Abx Rx in
US
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
THE URI PROBLEMothe
r
↑
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
THE URI PROBLEMothe
r
↑
Expectations
Liability
Press-Ganey
SpeedEase
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
other
↑THE URI PROBLEM
Convenient ≠ Appropriate
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
URIsCOMPLICATIONS
EVIDENCE-BASED
MANAGEMENT
DO THE RIGHT THING“A physician who merely
spreads an array of vendibles in front of the patient and then says, ‘Go ahead and choose, it’s your life’ does not warrant the still distinguished title of doctor.”
Franz Ingelfinger, M.D.Editor, NEJM
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
URI
URI PROBLEM
TREATMENT
URIsRECS
EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
This attending is a part-owner in The Barkley, a luxury pet hotel
and spa in Los Angeles.
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
URI PROBLEM
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
DAVID OBERT, D.O.
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
URI PROBLEM
TREATMENT
URIsTRIVIA
EVIDENCE-BASED
MANAGEMENT
EBM FOR URI“Don’t waste time finding the evidence for things that just don’t matter.”
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
EBM FOR URIFinding the best evidence:
URI
OTITIS SINUSITIS PHARYNGITIS
BRONCHITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
EBM FOR URI
OTITIS SINUSITIS PHARYNGITIS
BRONCHITIS
CHRONIC ACUTE ALLERGIC
Finding the best evidence:TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
EBM FOR URITRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
EBM FOR URITRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
EBM FOR URITRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
EBM FOR URI
• Nearly always viral• Antibiotics are useless• “Purulent” secretions common
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
URIsSINUSITIS
EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
Four attendings own Porshes.Name any three:
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
ROSS BERKELEY, M.D., NICK SADEGHI, M.D.,
GLEN GUILLERMO, M.D.
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
TREATMENT
URIsDOGMA
EVIDENCE-BASED
MANAGEMENT
ACUTE OTITIS MEDIA (AOM)
IN ADULTS
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
AOM - DEFINITION
• Infection or inflammation of the middle ear
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
EPIDEMIOLOGY
• >80% of children
• Incidence drops after age 7
• Adult incidence only 0.25%
Brownlee RC, DeLoache WR, Cowan CC, Jackson HP. Otitis media in children: Incidence, treatment and prognosis in pediatric practice. J Pediatr. 1969; 75:636.
Schwartz LE, Brown RB. Purulent otitis media in adults. Arch Int Med. 1992;152(11):2301-4.
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
AOM - FEATURES
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
COMPICATIONS
Intratemporal• Mastoiditis/Petrositis• Labyrinthitis/hearing lossExtratemporal• Abscess• Meningitis• Lateral sinus thrombosis
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TREATMENT
URIsWARNING
EVIDENCE-BASED
MANAGEMENT
AOM - TREATMENT
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
AOM - TREATMENTWARNING
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
AOM - TREATMENTWARNING
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
AOM - TREATMENT
• Adult – no data on withholding antibiotics
• Microbiology – • 25-50% viral• S. pneumoniae – 20% resolve• H. influenza – 50% resolve
WARNING
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
TREATMENT
URIsPROBLEM
EVIDENCE-BASED
MANAGEMENT
COMPLICATIONS
Eur Arch Otorhinolaryg. 2010;267:1855-61
WARNING
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
COMPLICATIONSPROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TREATMENT
URIs EVIDENCE-BASED
MANAGEMENT
AOM - RECs
1. Adult AOM no initial Abx
2. Complications → Abx
3. Treat eustachian tube dysfxn
4. Recheck
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
TREATMENT
EBM
URIsSUMMARY
EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
Everyone knows Jim Preddy was a cheerleader. Name the other
former cheerleader:
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
EBM
URIs EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
JAMIE MEADE, M.D.
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
EBM
URIsRECS
EVIDENCE-BASED
MANAGEMENT
ACUTE SINUSITISIN ADULTS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
RECS
EBM
URIs EVIDENCE-BASED
MANAGEMENT
SINUSITISrhinosinusitis
RHINOSINUSITISACUTE
ABRS
AVRS
RECURRENTINFECT.
ALLERG.
CHRONICPOLYPS
NO POLYPS
FUNGAL
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
RECS
EBM
URIsTRIVIA
EVIDENCE-BASED
MANAGEMENT
THE DOGMAAVRS
7-10 daysSelf-limited
BilateralNon-purulent
98%-99.5%
ABRS>10 daysNeeds TxUnilateralPurulent
Facial pain0.5%-2%
Fokkens W, Lund V, Mullol J. European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology. 2007;45(2):97.
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
URIs EVIDENCE-BASED
MANAGEMENT
RHINOSINUSITIS
Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72
• Historical featuresFAILTRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
URIs EVIDENCE-BASED
MANAGEMENT
RHINOSINUSITIS
• Historical features• Physical exam
FAIL
FAIL
Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
URIs EVIDENCE-BASED
MANAGEMENT
RHINOSINUSITIS
Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I. Evaluation. Am Fam Physician. 2004 Nov 1;70(9):1685-92.
• Historical features• Physical exam• Purulence
FAIL
FAIL
FAIL
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
URIs EVIDENCE-BASED
MANAGEMENT
RHINOSINUSITIS
Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med. 1994;330(1):25
• Historical features• Physical exam• Purulence• Radiology
FAIL
FAIL
FAIL
FAILEPIC
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
URIsPHARYNGITIS
EVIDENCE-BASED
MANAGEMENT
WARNINGS
OCCULAR/ORBITAL
SEVEREHEADACHE
FACIALSWELLING
ALTEREDMENTATION
Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Centers for Disease Control and
Prevention. Annals of Emergency Medicine. 2001;37(6):703-10
• No cases due to placebo
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
EBM
URIsSTREP
EVIDENCE-BASED
MANAGEMENT
THE PROBLEM
• Antibiotics – >80%!!!
Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Centers for Disease Control and
Prevention. Annals of Emergency Medicine. 2001;37(6):703-10
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
EBM
URIsTRIVIA
EVIDENCE-BASED
MANAGEMENT
RHINOSINUSITIS
Systematic Review
Williams JW Jr, Aguilar C, Makela M, et al. Antibiotic therapy for acute sinusitis: a systematic literature review. In: Douglas R, et al., eds. Acute Respiratory Infections Module of The Cochrane Database of Systematic Reviews. The Cochrane Library.
1997.
ABX47% at 10-
14d81% Cure
No ABX32% at 10-
14d66% Cure
NNT = 7
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
EBM
URIs EVIDENCE-BASED
MANAGEMENT
RHINOSINUSITIS
Stalman W, van Essen GA, et al. Br J Gen Pract. 1997;47:794-9
Lancet. 1997;349:683-7
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
EBM
URIs EVIDENCE-BASED
MANAGEMENT
RHINOSINUSITIS
Lancet Infect Dis. 2008;8(9):543
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
EBM
URIsCENTOR
EVIDENCE-BASED
MANAGEMENT
SUMMARY
Disease rare
Diagnosis difficult
Mostly harmless
Treatment modest
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
EBM
URIs EVIDENCE-BASED
MANAGEMENT
SUMMARY
80%
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
EBM
URIsRECS
EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Int Med. 2001;134(6):495-97
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
EBM
URIs EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
SINCE:• Most ARS is viral• Bacterial/viral cannot be
differentiated• Most ABRS improves without Tx
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
EBM
URIs EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
RECOMMENDED:• Symptomatic Tx and
reassurance• Pain medication• Decongestants
• Abx only for severe symptoms• Cover for strep and haemophilus• Sx must be present >7 days
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
EBM
URIsBRONCHITIS
EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
To my knowledge, this is the only EM attending in the world who
has survived an ED thoracotomy.
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
URIs EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
JOSHUA PARKER, M.D.
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
URIsEVALUATION
EVIDENCE-BASED
MANAGEMENT
ACUTE PHARYNGITIS
IN ADULTS
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
URIs EVIDENCE-BASED
MANAGEMENT
SORE THROAT
EPIGLOTTITIS CANCERS ABSCESS
LARYNGITIS PHARYNGITISTHYROIDITIS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
URIs EVIDENCE-BASED
MANAGEMENT
PHARYNGITIS
EXUDATIVE NON-EXUDATIVE
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
URIs EVIDENCE-BASED
MANAGEMENT
PHARYNGITIS(Exudative)
STREPTOCOCCAL DIPTHERIA
GONOCCOCAL MONONUCLEOSIS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
URIs EVIDENCE-BASED
MANAGEMENT
EPIDEMIOLOGY
27 million ED visits/year• Peds – 30% GABHS• Adult – 5-10% GABHS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
URIsRECS
EVIDENCE-BASED
MANAGEMENT
STREP PHARYNGITISRationale for treatment:
• Prevent post-strep sequelae• Rheumatic fever• Post-strep glomerulonephritis
• Prevent abscess• Reduce transmission• Relieve symptoms
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
URIs EVIDENCE-BASED
MANAGEMENT
STREP PHARYNGITISRheumatic Fever:
• RF 60-fold less common now• 1954: NNT = 63• 2012: NNT = 3000-4000
Catanzaro FJ, Stetson CA, et al. The role of the streptococcus in the pathogenesis of rheumatic fever. Am J Med. 1954;17:749-56.
Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (CochraneReview). In: The Cochrane Library, Issue 3, 1999. Oxford
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
URIs EVIDENCE-BASED
MANAGEMENT
STREP PHARYNGITISPost-streptoccocal G.N.:
• No evidence that Abx help• Extremely rare
Goslings WR, et al. Attack rates of streptococcal pharyngitis, rheumatic fever and glomerulonephritis in the general population. N Engl J Med. 1963;268:687-94.
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
URIs EVIDENCE-BASED
MANAGEMENT
STREP PHARYNGITISPost-streptoccocal G.N.:
• No evidence that Abx help
Peritonsillar Abscess• 56% - abscess already present• Only 25% PTAs are +GABHS
Webb KH, et al. Use of a high-sensitivity rapid strep test without culture confirmation of negative results: 2 years’ experience. J Fam Pract. 2000;49:34-8
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
URIs EVIDENCE-BASED
MANAGEMENT
STREP PHARYNGITISPrevention of
transmission:• Small effect in schools• Unknown in adults
Krober MS, Bass JW, Michels GN. Streptococcal pharyngitis. Placebo-controlled double-blind evaluation of clinical response to penicillin therapy. JAMA. 1985;253:1271-4.
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
URIs EVIDENCE-BASED
MANAGEMENT
STREP PHARYNGITISPrevention of
transmission:• Small effect in schools
Relief of symptoms:• Hastens relief by 1 day• Sx duration r/t satisfactionLittle P, Williamson I, Warner G, et al. Open randomised trial of prescribing
strategies in managing sore throat. BMJ.1997;314:722-7
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
URIs EVIDENCE-BASED
MANAGEMENT
STREP PHARYNGITISRationale for treatment:
• Prevent post-strep sequelae• Rheumatic fever• Post-strep glomerulonephritis
• Prevent abscess• Reduce transmission• Relieve symptoms
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
URIsTRIVIA
EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
This attending is an avid runner with a personal-best marathon
time of 2:49!
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
URIs EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
JD MCCOURT, M.D.
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STREP
PHARYNGITIS
URIsSUMMARY
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MANAGEMENT
STREP PHARYNGITIS
McIsaac et al., JAMA 2004, 291:1587-95
The Modified Centor Score
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STREP PHARYNGITIS
SUMMARY
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RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
URIsEND
EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
SUMMARY
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EVALUATION
BRONCHITIS
RECS
CENTOR
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URIs EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
1. 10% pharyngitis is GABHS
2. Abx only for GABHS3. Use 1 of 3 strategies4. Culture should be only
for surveillance
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SUMMARY
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BRONCHITIS
RECS
CENTOR
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URIs EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
3. Use 1 of 3 strategies:A. 2-4 Centor criteria -• Rapid antigen test• Treat only positives
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SUMMARY
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EVALUATION
BRONCHITIS
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CENTOR
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URIs EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
3. Use 1 of 3 strategies:B. 2-3 Centor criteria -• Rapid antigen test• Treat positives• 4 Centor criteria - treat
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SUMMARY
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EVALUATION
BRONCHITIS
RECS
CENTOR
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URIs EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
3. Use 1 of 3 strategies:C. 3-4 Centor criteria - treat• Don’t use any testing
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SUMMARY
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URIs EVIDENCE-BASED
MANAGEMENT
ACUTE BRONCHITISIN ADULTS
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MANAGEMENT
COUGH
ASTHMA BRONCHITIS
PULM EMBOLISM PNEUMONIA MASS
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MANAGEMENT
BRONCHITISBRONCHITIS
ACUTE
INFECTBACTERIAL
VIRAL
REACTIVE
CHEMICAL
ALLERGIC
CHRONICEND
SUMMARY
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EVALUATION
BRONCHITIS
RECS
CENTOR
URIs EVIDENCE-BASED
MANAGEMENT
ACUTE BRONCHITIS• Incidence 5%/year
• Acute = 3 weeks• As opposed to URI:
90% present for evalGonzales R, Wilson A, et al. What’s in a name? Public knowledge, attitudes, and experiences with antibiotic use for acute bronchitis. Am J Med. 2000;108:83-5
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URIs EVIDENCE-BASED
MANAGEMENT
EVALUATION
Metlay JP, Kapoor WN, Fine MJ. Does this patient have community acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA.
1997;278:1440-5.
CXR unnecessary if:• Vitals normal• HR < 100, RR < 24, T < 38
• No abnormal breath sounds• Assymetric or focal
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SUMMARY
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URIs EVIDENCE-BASED
MANAGEMENT
EVALUATION
Ralph Gonzales, Paul H Barrett, Jr., John F Steiner. The Relation Between Purulent Manifestations and Antibiotic Treatment of Upper Respiratory Tract Infections
J Gen Intern Med. 1999 March; 14(3): 151–156.
• OR 0.25 for bacterial cause• OR 4.8 for Abx prescription
END
SUMMARY
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EVALUATION
BRONCHITIS
RECS
URIs EVIDENCE-BASED
MANAGEMENT
RECOMMENDATION
No antibiotics for uncomplicated bronchitis
regardless of duration.
Only exception: pertussis
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SUMMARY
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EVALUATION
BRONCHITIS
URIs EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
This attending is a former water polo player:
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SUMMARY
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EVALUATION
URIs EVIDENCE-BASED
MANAGEMENT
ATTENDING TRIVIA
KETAN PATEL, M.D.
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SUMMARY
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URIs EVIDENCE-BASED
MANAGEMENT
SUMMARY1. URIs and their component
illnesses are usually viral.
2. Even when complicated by bacterial infections antibiotics are rarely necessary.END
SUMMARY
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SUMMARY3. Make antibiotic decisions based
on the most prominent feature.
4. The default should be no antibiotics unless overwhelming evidence of bacterial infection.
5. Go E.A.S.T.
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SUMMARY
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URIs EVIDENCE-BASED
MANAGEMENT
END
SUMMARY
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URIs EVIDENCE-BASED
MANAGEMENT
END
SUMMARY
TRIVIA