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Upper Respiratory Tract Infection
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Upper Respiratory Infections

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Nathan Cleveland, MD, MS

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Upper Respiratory Infections

  1. 1. EVIDENCE-BASED MANAGMENT NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 3 OCTOBER 2012
  2. 2. TITLE TRIVIA INTRO GOALS EBM CASE URI URI PROBLEM EVIDENCE- BASED MANAGEMENT
  3. 3. RIGHT THING EVIDENCE- BASED MANAGEMENT TITLE TRIVIA INTRO GOALS EBM CASE URI URI PROBLEM
  4. 4. EVIDENCE- BASED MANAGEMENT RULE #1 – Determine sick vs not-sick RULE #2 – Vitals are vital RULE #3 – Risk stratify everybody PATIENT LR HR CC LR HR 43 21 RIGHT THING TITLE TRIVIA INTRO GOALS EBM CASE URI URI PROBLEM
  5. 5. EVIDENCE- BASED MANAGEMENT RULE #1 – Determine sick vs not-sick RULE #2 – Vitals are vital RULE #3 – Risk stratify everybody RULE #4 – Go Early Aggressive Symptom Treatment RIGHT THING TITLE TRIVIA INTRO GOALS EBM CASE URI URI PROBLEM
  6. 6. TRIVIA EVIDENCE- BASED MANAGEMENT Reflexive care requires up-front knowledge of the current best available evidence. RIGHT THING TRIVIA INTRO GOALS EBM CASE URI URI PROBLEM
  7. 7. EBM FOR URI EVIDENCE- BASED MANAGEMENT 1. The URI problem 2. Abx management of: • Otitis media • Sinusitis • Pharyngitis • Bronchitis TRIVIA RIGHT THING TRIVIA GOALS EBM CASE URI URI PROBLEM
  8. 8. EVIDENCE- BASED MANAGEMENT 3. Recommendations 4. Attending trivia EBM FOR URI TRIVIA RIGHT THING TRIVIA GOALS EBM CASE URI URI PROBLEM
  9. 9. TRIVIA EVIDENCE- BASED MANAGEMENT Four attendings are Eagle Scouts. Name any two: EBM FOR URI TRIVIA RIGHT THING TRIVIA GOALS EBM URI URI PROBLEM
  10. 10. EVIDENCE- BASED MANAGEMENT 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
  11. 11. OTITIS EVIDENCE- BASED MANAGEMENT NASAL CONGESTION FEVER / CHILLS SORE THROAT SINUS PRESSURERUNNY NOSE COUGH EARACHE URI TRIVIA EBM FOR URI TRIVIA RIGHT THING TRIVIA GOALS URI URI PROBLEM
  12. 12. EVIDENCE- BASED MANAGEMENT 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
  13. 13. EVIDENCE- BASED MANAGEMENT • 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
  14. 14. EVIDENCE- BASED MANAGEMENT The “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
  15. 15. EVIDENCE- BASED MANAGEMENT • 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
  16. 16. EVIDENCE- BASED MANAGEMENT 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. • Doctor visit = antibiotics • 60% are prescribed antibiotic OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TRIVIA URI URI PROBLEM TREATMENT
  17. 17. EVIDENCE- BASED MANAGEMENT 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. • 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
  18. 18. EVIDENCE- BASED MANAGEMENT OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TRIVIA URI URI PROBLEM TREATMENT
  19. 19. EVIDENCE- BASED MANAGEMENT Liability Ease OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TRIVIA URI URI PROBLEM TREATMENT
  20. 20. EVIDENCE- BASED MANAGEMENT Convenient ≠ Appropriate OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TRIVIA URI URI PROBLEM TREATMENT
  21. 21. COMPLICATIONS EVIDENCE- BASED MANAGEMENT “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
  22. 22. RECS EVIDENCE- BASED MANAGEMENT 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
  23. 23. EVIDENCE- BASED MANAGEMENT DAVID OBERT, D.O. RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING URI PROBLEM TREATMENT
  24. 24. TRIVIA EVIDENCE- BASED MANAGEMENT “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
  25. 25. EVIDENCE- BASED MANAGEMENT Finding the best evidence: URI OTITIS SINUSITIS PHARYNGITIS BRONCHITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TREATMENT
  26. 26. EVIDENCE- BASED MANAGEMENT OTITIS SINUSITIS PHARYNGITIS BRONCHITIS CHRONIC ACUTE ALLERGIC Finding the best evidence:TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TREATMENT
  27. 27. EVIDENCE- BASED MANAGEMENT TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TREATMENT
  28. 28. EVIDENCE- BASED MANAGEMENT TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TREATMENT
  29. 29. EVIDENCE- BASED MANAGEMENT TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TREATMENT
  30. 30. EVIDENCE- BASED MANAGEMENT • Nearly always viral • Antibiotics are useless • “Purulent” secretions common TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA RIGHT THING TREATMENT
  31. 31. SINUSITIS EVIDENCE- BASED MANAGEMENT Four attendings own Porshes. Name any three: TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA TREATMENT
  32. 32. EVIDENCE- BASED MANAGEMENT ROSS BERKELEY, M.D., NICK SADEGHI, M.D., GLEN GUILLERMO, M.D. SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TRIVIA TREATMENT
  33. 33. DOGMA EVIDENCE- BASED MANAGEMENT SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TREATMENT
  34. 34. EVIDENCE- BASED MANAGEMENT • Infection or inflammation of the middle ear DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TREATMENT
  35. 35. EVIDENCE- BASED MANAGEMENT • >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
  36. 36. EVIDENCE- BASED MANAGEMENT DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TREATMENT
  37. 37. EVIDENCE- BASED MANAGEMENT Intratemporal • Mastoiditis/Petrositis • Labyrinthitis/hearing loss Extratemporal • Abscess • Meningitis • Lateral sinus thrombosis DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA EBM FOR URI TREATMENT
  38. 38. WARNING EVIDENCE- BASED MANAGEMENT DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA TREATMENT
  39. 39. EVIDENCE- BASED MANAGEMENT WARNING DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA TREATMENT
  40. 40. EVIDENCE- BASED MANAGEMENT WARNING DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TRIVIA TREATMENT
  41. 41. EVIDENCE- BASED MANAGEMENT • 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
  42. 42. PROBLEM EVIDENCE- BASED MANAGEMENT Eur Arch Otorhinolaryg. 2010;267:1855-61 WARNING DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TREATMENT
  43. 43. EVIDENCE- BASED MANAGEMENT PROBLEM WARNING DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS OTITIS TREATMENT
  44. 44. EVIDENCE- BASED MANAGEMENT 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
  45. 45. SUMMARY EVIDENCE- BASED MANAGEMENT Everyone knows Jim Preddy was a cheerleader. Name the other former cheerleader: PROBLEM WARNING DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS EBM
  46. 46. EVIDENCE- BASED MANAGEMENT JAMIE MEADE, M.D. SUMMARY PROBLEM WARNING DOGMA SINUSITIS TRIVIA RECS COMPLICATIONS EBM
  47. 47. RECS EVIDENCE- BASED MANAGEMENT SUMMARY PROBLEM WARNING DOGMA SINUSITIS TRIVIA RECS EBM
  48. 48. EVIDENCE- BASED MANAGEMENT RHINOSINUSITIS ACUTE ABRS AVRS RECURRENT INFECT. ALLERG. CHRONIC POLYPS NO POLYPS FUNGAL RECS SUMMARY PROBLEM WARNING DOGMA SINUSITIS TRIVIA RECS EBM
  49. 49. TRIVIA EVIDENCE- BASED MANAGEMENT AVRS 7-10 days Self-limited Bilateral Non-purulent 98%-99.5% ABRS >10 days Needs Tx Unilateral Purulent Facial pain 0.5%-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
  50. 50. EVIDENCE- BASED MANAGEMENT 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 featuresTRIVIA RECS SUMMARY PROBLEM WARNING DOGMA SINUSITIS TRIVIA EBM
  51. 51. EVIDENCE- BASED MANAGEMENT • Historical features • Physical exam 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
  52. 52. EVIDENCE- BASED MANAGEMENT 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 TRIVIA RECS SUMMARY PROBLEM WARNING DOGMA SINUSITIS TRIVIA EBM
  53. 53. EVIDENCE- BASED MANAGEMENT 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 TRIVIA RECS SUMMARY PROBLEM WARNING DOGMA SINUSITIS TRIVIA EBM
  54. 54. PHARYNGITIS EVIDENCE- BASED MANAGEMENT OCCULAR/ ORBITAL SEVERE HEADACHE FACIAL SWELLING ALTERED MENTATION 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
  55. 55. STREP EVIDENCE- BASED MANAGEMENT • 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
  56. 56. TRIVIA EVIDENCE- BASED MANAGEMENT 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. ABX 47% at 10-14d 81% Cure No ABX 32% at 10-14d 66% Cure NNT = 7 STREP PHARYNGITIS TRIVIA RECS SUMMARY PROBLEM WARNING EBM
  57. 57. EVIDENCE- BASED MANAGEMENT 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
  58. 58. EVIDENCE- BASED MANAGEMENT Lancet Infect Dis. 2008;8(9):543 TRIVIA STREP PHARYNGITIS TRIVIA RECS SUMMARY PROBLEM WARNING EBM
  59. 59. CENTOR EVIDENCE- BASED MANAGEMENT Disease rare Diagnosis difficult Mostly harmless Treatment modest TRIVIA STREP PHARYNGITIS TRIVIA RECS SUMMARY PROBLEM EBM
  60. 60. EVIDENCE- BASED MANAGEMENT 80% CENTOR TRIVIA STREP PHARYNGITIS TRIVIA RECS SUMMARY PROBLEM EBM
  61. 61. RECS EVIDENCE- BASED MANAGEMENT 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
  62. 62. EVIDENCE- BASED MANAGEMENT SINCE: • Most ARS is viral • Bacterial/viral cannot be differentiated • Most ABRS improves without Tx RECS CENTOR TRIVIA STREP PHARYNGITIS TRIVIA RECS SUMMARY EBM
  63. 63. EVIDENCE- BASED MANAGEMENT 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
  64. 64. BRONCHITIS EVIDENCE- BASED MANAGEMENT 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
  65. 65. EVIDENCE- BASED MANAGEMENT JOSHUA PARKER, M.D. BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS TRIVIA RECS SUMMARY
  66. 66. EVALUATION EVIDENCE- BASED MANAGEMENT BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS TRIVIA RECS
  67. 67. EVIDENCE- BASED MANAGEMENT EPIGLOTTITIS CANCERS ABSCESS LARYNGITIS PHARYNGITISTHYROIDITIS EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS TRIVIA RECS
  68. 68. EVIDENCE- BASED MANAGEMENT EXUDATIVE NON-EXUDATIVE EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS TRIVIA RECS
  69. 69. EVIDENCE- BASED MANAGEMENT STREPTOCOCCAL DIPTHERIA GONOCCOCAL MONONUCLEOSIS EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS TRIVIA RECS
  70. 70. EVIDENCE- BASED MANAGEMENT 27 million ED visits/year • Peds – 30% GABHS • Adult – 5-10% GABHS EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS TRIVIA RECS
  71. 71. RECS EVIDENCE- BASED MANAGEMENT Rationale 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
  72. 72. EVIDENCE- BASED MANAGEMENT Rheumatic 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 (Cochrane Review). In: The Cochrane Library, Issue 3, 1999. Oxford RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS TRIVIA
  73. 73. EVIDENCE- BASED MANAGEMENT Post-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
  74. 74. EVIDENCE- BASED MANAGEMENT Post-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
  75. 75. EVIDENCE- BASED MANAGEMENT Prevention 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
  76. 76. EVIDENCE- BASED MANAGEMENT Prevention of transmission: • Small effect in schools Relief of symptoms: • Hastens relief by 1 day • Sx duration r/t satisfaction Little 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
  77. 77. EVIDENCE- BASED MANAGEMENT Rationale 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
  78. 78. TRIVIA EVIDENCE- BASED MANAGEMENT This attending is an avid runner with a personal-best marathon time of 2:49! RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS
  79. 79. EVIDENCE- BASED MANAGEMENT JD MCCOURT, M.D. TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP PHARYNGITIS
  80. 80. SUMMARY EVIDENCE- BASED MANAGEMENT McIsaac et al., JAMA 2004, 291:1587-95 The Modified Centor Score TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP
  81. 81. EVIDENCE- BASED MANAGEMENT SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA STREP
  82. 82. END EVIDENCE- BASED MANAGEMENT SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA
  83. 83. EVIDENCE- BASED MANAGEMENT 1. 10% pharyngitis is GABHS 2. Abx only for GABHS 3. Use 1 of 3 strategies 4. Culture should be only for surveillance END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA
  84. 84. EVIDENCE- BASED MANAGEMENT 3. Use 1 of 3 strategies: A. 2-4 Centor criteria - • Rapid antigen test • Treat only positives END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA
  85. 85. EVIDENCE- BASED MANAGEMENT 3. Use 1 of 3 strategies: B. 2-3 Centor criteria - • Rapid antigen test • Treat positives • 4 Centor criteria - treat END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA
  86. 86. EVIDENCE- BASED MANAGEMENT 3. Use 1 of 3 strategies: C. 3-4 Centor criteria - treat • Don‟t use any testing END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR TRIVIA
  87. 87. EVIDENCE- BASED MANAGEMENT END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR
  88. 88. EVIDENCE- BASED MANAGEMENT ASTHMA BRONCHITIS PULM EMBOLISM PNEUMONIA MASS END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR
  89. 89. EVIDENCE- BASED MANAGEMENT BRONCHITIS ACUTE INFECT BACTERIAL VIRAL REACTIVE CHEMICAL ALLERGIC CHRONICEND SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR
  90. 90. EVIDENCE- BASED MANAGEMENT • Incidence 5%/year • Acute = 3 weeks • As opposed to URI: 90% present for eval Gonzales 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 END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS CENTOR
  91. 91. EVIDENCE- BASED MANAGEMENT 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 END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS RECS
  92. 92. EVIDENCE- BASED MANAGEMENT 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 TRIVIA RECS EVALUATION BRONCHITIS RECS
  93. 93. EVIDENCE- BASED MANAGEMENT No antibiotics for uncomplicated bronchitis regardless of duration. Only exception: pertussis END SUMMARY TRIVIA RECS EVALUATION BRONCHITIS
  94. 94. EVIDENCE- BASED MANAGEMENT This attending is a former water polo player: END SUMMARY TRIVIA RECS EVALUATION
  95. 95. EVIDENCE- BASED MANAGEMENT KETAN PATEL, M.D. END SUMMARY TRIVIA RECS EVALUATION
  96. 96. EVIDENCE- BASED MANAGEMENT 1. URIs and their component illnesses are usually viral. 2. Even when complicated by bacterial infections antibiotics are rarely necessary.END SUMMARY TRIVIA RECS
  97. 97. EVIDENCE- BASED MANAGEMENT 3. 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. END SUMMARY TRIVIA RECS
  98. 98. EVIDENCE- BASED MANAGEMENT END SUMMARY TRIVIA
  99. 99. EVIDENCE- BASED MANAGEMENT END SUMMARY TRIVIA
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Nathan Cleveland, MD, MS

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