Upper Respiratory Infections

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Nathan Cleveland, MD, MS

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  • So, you walk into a teaching shift in the main ED. You start scanning the board for interesting cases you could see with the medical student and this is what jumps out at you. You think to yourself, “This is gonna be good!” So you scroll through the triage info and this is what you find.
  • So, you walk into a teaching shift in the main ED. You start scanning the board for interesting cases you could see with the medical student and this is what jumps out at you. You think to yourself, “This is gonna be good!” So you scroll through the triage info and this is what you find.
  • So, you walk into a teaching shift in the main ED. You start scanning the board for interesting cases you could see with the medical student and this is what jumps out at you. You think to yourself, “This is gonna be good!” So you scroll through the triage info and this is what you find.
  • So, you walk into a teaching shift in the main ED. You start scanning the board for interesting cases you could see with the medical student and this is what jumps out at you. You think to yourself, “This is gonna be good!” So you scroll through the triage info and this is what you find.
  • Which brings up an important evidence-based medicine principle: If you are going to practice safe reflexive care (ie I see X therefore I do Y with very little thought) you have to know what the literature says ahead of time. If you don’t want to think in the department, you have to have already thought about the scenario, in detail, before.
  • First, we’re going to talk about the URI problem and talk briefly about a diagnostic approach to URIs. Second, we’re going to focus on current best evidence regarding antibiotic management of…
  • Third we’ll focus on some specific evidence-based recommendation. And finally, the return of beer trivia.
  • Defining the syndrome that we all refer to as URI is really difficult. Although I’m going to use that term for the rest of the lecture, it probably is not a very good term to use. URI can refer to any or all of the following symptoms… and you could probably throw in headache, sneezing and sometimes vomiting/diarrhea.
  • Which brings up an important (but as far as I know, non-evidence based) principle that… Every viral illness includes a period of viremia – therefore multiple systems involved. If a bacterial illness involves a period of bacteremia, expect that pt to be sick.
  • One of the problems is that due to the poor definition for URI, it is a very difficult entity to study. In the largest study of the etiology of the common cold, a potential causative organism was only isolated in 7% of patients. Keep in mind that many of these may have only been colonizations and not the direct cause of the syndrome.
  • So, at least with the syndrome that we define as “common cold” it appears that nearly all cases are viral.
  • So we do we even care about the common cold? I mean we went into EM to take care of STEMIs and sepsis and gunshot wounds right? Well, part of the reason we need to know about it is because you are going to see a lot of it in your career.
  • The other reason to know the best evidence on managing the common cold is to avoid the other URI problem we are dealing with. Doctors continue to prescribe antibiotics for URIs. Paper after paper has documented the frequency of this practice. Currently, it is believed that almost 60% of people who present to a doctor for the common cold will be prescribed antibiotics.
  • And this is what pts want. Symptomatic treatment really doesn’t work that well and pts don’t really understand the arguments against antibiotics.
  • And it’s not hard to see how antibiotics happen. A lot of times at work we feel a little like this island where the combined pressures of pt expectations, fear of liability, easing the pt interaction, moving fast and pt satisfaction lead to the easiest solution which is hand them a prescription for antibiotics.
  • But convenient does not always mean appropriate, right?
  • Let me encourage you to do the right thing. I love this quote from the former editor of the New England Journal… It’s not a buffet line, right?
  • Well, you might say, “I’ve heard you say that we should not waste time…” for instance, should we be recommending ice for sprains. Because a non-surgical sprain is a self-limited condition (regardless of what we do for it) I choose not to spend my time looking up this data. You might say the same thing about URIs. Since it is a self-limited condition, no matter what we do, why waste our time looking at the data with regards to antibiotics. Hopefully as we go through some of the evidence, I’ll be able to convince you that it does, in fact, matter.
  • Since URI is such a broad and poorly defined syndrome, finding any good evidence on treatment is difficult. In order to find any high-level evidence, it has to be broken down into the separate components that make up the syndrome.
  • For each of these entities, you could subdivide into chronic, acute and allergic etiologies. Suffice it to say that chronic and allergic forms are almost never emergencies, therefore we’re not going to talk about those today. We’ll focus the evidence on the acute form.
  • Back in 2001, some pretty heavy hitters in medicine formed a task force to review the current best evidence on managing URI. I don’t know why but I had never heard of the papers that this group produced until I started doing literature review for this talk. I don’t know why that is (maybe because URI is boring to most of us) but the result papers from this task force should be required reading for all EM and primary care doctors. Somehow this information seems to have not influenced the practice behaviors of most doctors in this country.
  • Although they never came right out and said it. This task force essentially advocated the idea of focusing on the most prominent feature of the patient’s URI and making management decisions based on that rather than “URI” in general. They produced the following four papers which were published in AIM and reproduced in AEM and AFP.
  • Well, you might say, “I’ve heard you say that we should not waste time…” for instance, should we be recommending ice for sprains. Because a non-surgical sprain is a self-limited condition (regardless of what we do for it) I choose not to spend my time looking up this data. You might say the same thing about URIs. Since it is a self-limited condition, no matter what we do, why waste our time looking at the data with regards to antibiotics. Hopefully as we go through some of the evidence, I’ll be able to convince you that it does, in fact, matter.
  • Just a simple review of basic anatomy and pathophysiology… The common precipitating factor in nearly all cases of otiris is eustachian tube dysfunction. This usually occurs as a result of viral infection (URI) or allergy. Lack of aeration and drainage leads to a closed, warm, moist compartment and bacteria can infect.
  • Just a simple review of basic anatomy and pathophysiology… The common precipitating factor in nearly all cases of otiris is eustachian tube dysfunction. This usually occurs as a result of viral infection (URI) or allergy. Lack of aeration and drainage leads to a closed, warm, moist compartment and bacteria can infect.
  • Now most of us could make the diagnosis of purulent (or bacterial) AOM if we saw this TM or that TM. The problem is, what do we do with this one or this one or this one??
  • Complications include… and these are the real reasons to treat with antibiotics, but they are extremely rare.
  • There is very little high’level evidence on treating AOM in the adult population. Now both the AAP and AAFP have come out with guidelines in 2004 stating that observation, even for purulent otitis, is an appropriate option. This recommendation is based on the following data…
  • This is meta-analysis data from dozens of studies over 30 years. Take a look at a few things… If you look at clinical resolution at 7 days, the NNT with antibiotics is 8. If you look here at antibiotic induced diarrhea or vomiting, the NNH with antibiotics is 6.
  • But we all know that adults are not just big kids. To me, one of the biggest differences between the two is that adults can go back to the doctor if they are feeling worse, whereas children cannot. But what does the adult literature say?
  • As I mentioned, unfortunately there is no data on withholding antibiotics from adults with AOM. The next best thing is to look at the microbiology of AOM and make some inferences about treatment.
  • Well, what about those dangerous complications of AOM?? They are extremely rare. This study in Sweden found less than 10 cases ofmastoiditis yearly and no increase in incidence after their new recommendations not to treat otitis with antibiotics. If you look at adults only you see that over a 10 year period, there were only 3 cases of mastoiditis and 2/3 had had previous surgery of the temporal bone.
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications. Again, less than 10/year.
  • Sinusitis is defined as inflammation of the paranasal sinuses and airspaces of the face due to infection, allergy or other inflammation. Acute sinusitis refers to these symptoms lasting less than 4 weeks. Subacute lasts from 4-12 weeks and chronic is sinusitis lasting greater than 12 weeks.
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • There are 27 million visits/year to US EDs for sore throat. Probably hundreds of millions of visits to all ambulatory environments. The differential for sore throat is actually quite large. Before we get to the discussion of pharyngitis, let’s just go through a few of the other conditions you should be aware of when a pt c/o ST.
  • Once you have established that you are dealing with pharyngitis and not another cause of sore throat, the first step is to determine whether it is exudative or non-exudative.
  • Exudative pharyngitis is not always strep. Consider…
  • There are 27 million visits/year to US EDs for sore throat. Probably hundreds of millions of visits to all ambulatory environments. The differential for sore throat is actually quite large. Before we get to the discussion of pharyngitis, let’s just go through a few of the other conditions you should be aware of when a pt c/o ST.
  • Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
  • Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
  • Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
  • Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
  • A few RCTs have shown that abx reduce sx duration by about 1 day. More recently studies have shown that pt report of sx is largely related to the pt’s satisfaction with the doctors treatment strategy.
  • A few RCTs have shown that abx reduce sx duration by about 1 day. More recently studies have shown that pt report of sx is largely related to the pt’s satisfaction with the doctors treatment strategy.
  • Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
  • Post-strep sequelae
  • DOGMA
  • Similar results in Finland where they looked at all intratemporal and extratemporal complications
  • Of those that present for evaluation of cough in the ambulatory setting, 70% are bronchitis, the next most common dx are asthma 6% and pneumonia 5%.
  • I was surprised by this but there is actually fairly robust data regarding when xray is needed for cough. There have been many attempts to develop clinical prediction rules but they all basically boil down to this.
  • Notably absent from all rules is the presence of “purulent” sputum which has been shown to be present in pneumonia, bacterial and viral bronchitis as well as sinusitis, common cold.
  • This recommendation is simple.
  • 5 simple summery points
  • This recommendation is simple.
  • 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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