RAC-king it – Evidence based style

1. RAC-king it – Evidence based style UIM 2013

2. Learning Objectives • Appropriately diagnose and treat acute rhinosinusitis • Appropriately diagnose and treat UTI • Appropriately diagnose and treat Pharyngitis • Appropriately diagnose and treat Cough • Appropriately diagnose and treat Gastroenteritis • Utilize an evidence-based approach to the diagnosis and treatment of acute low back pain • Utilize an evidence-based approach to the diagnosis and treatment of acute Joint pains/sprains • Appropriately diagnose and treat Vaginitis • Appropriately diagnose and treat Red eye

3. URI – “ Last time I needed an antibiotic” • Viral or Bacterial? • Rhinosinusitis symptoms lasting seven or more days and any of the following: • Purulent nasal discharge, (color does not matter!!) or • Maxillary tooth or facial pain, especially unilateral, or • Unilateral maxillary sinus tenderness, or • Worsening symptoms after initial improvement

4. Pharyngitis • Centor Criteria: • Tonsillar exudates • Tender anterior cervical adenopathy • Fever by history • Absence of cough • The absence of three or four of the criteria has a negative predictive value of 80 percent. • 140,000 individuals 15 years or older presenting with sore throat: the rate of confirmation of GAS (by either rapid streptococcal antigen testing or culture) for patients meeting one, two, three, or four criteria were 12, 21, 38, and 57 percent respectively

5. Pharyngitis • Fewer than 2 Centors: no culture, no treatment • 2+ Centors: rapid strep/culture and treat only if positive • Penicillin

6. Cough • 30 million clinician visits annually • Acute < 3 weeks – viral acute resp infection (acute bronchitis) • 60% of adults presenting with bronchitis treated with antibiotics • 75% of all antibiotics written are for URI’s • Purulent sputum does not indicate bacterial infection • Wheezing is common • Hemoptysis may occur • Fever suggests pneumonia or influenza

7. Subacute (3-8 weeks) and Chronic (>8 weeks) not a RAC w/u • Upper airway cough syndrome • Asthma • Gastroesophageal reflux- • Laryngopharyngeal reflux • Respiratory tract infection • ACE inhibitors • Chronic bronchitis • Bronchiectasis • Lung cancer • Nonasthmatic eosinophilic bronchitis • Rare causes

8. Acute Diarrhea (<14 days) • Most caused by viruses or self-limited bacterial • Evaluate volume status (orthostatics), temperature, peritoneal signs • Consider further evaluation/empiric antibiotics (oral fluoroquinolones) for: • Profuse watery diarrhea with signs of hypovolemia • Passage of many small volume stools containing blood and mucus • Bloody diarrhea • Temperature ≥38.5ºC (101.3ºF) • Passage of ≥6 unformed stools per 24 hours or a duration of illness >48 hours • Severe abdominal pain • Hospitalized patients or recent use of antibiotics • Diarrhea in the elderly (≥70 years of age) or the immunocompromised • Systemic illness with diarrhea, especially in pregnant women (in which case listeriosis should be suspected)

9. DO NOT TREAT WITH ANTIBIOTICS • Suspected EHEC (enterohemorrhagic E. coli) in patients with bloody diarrhea, abdominal pain and tenderness, but little or no fever • Suspected C. Difficile

10. Symptomatic Treatment of Acute Diarrhea • Loperamide (absent fever, no blood in stool) • Dipheoxylate – cholinergic side effects • Bismuth sulfate (can be used with fever, blood) • Probiotics • Clear liquids then advance – no high fat • Avoid lactose (for up to several months)

11. Antibiotic avoidance strategies • Treat symptoms – use a prescription if needed • Choosing Wisely –http://www.choosingwisely.org/ • http://www.cdc.gov/getsmart/resources/related-programs.html • 2008 NICE (National Institute for Health and Clinical Excellence) guidelines from the UK – patients should: • Be advised that the usual course and duration of illness is up to one and a half weeks for patients with a cold; symptoms persist an additional three days on average in smokers • Be informed regarding the risks and benefits of symptomatic management, including analgesics and antipyretics • Be informed and reassured that antibiotics are not needed and may have side effects • Have their concerns and expectations discussed • Be advised to return for review if their condition worsens or exceeds the expected time for recovery • When all else fails – delayed antibiotics (rhinosinusitis)

12. UTI • Uncomplicated • Women: • Dysuria and frequency without vag discharge – 90% probability of cystitis • Normal dipstick does not rule-out UTI • No culture needed • 3-7 days of treatment (not CIPRO – resistance!)

13. UTI vsPyleonephritis • Fever (>38ºC), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting • Culture • Start with Bactrim • Consider admission

14. UTI – Complicated: Culture and treat for 5-14 days • Diabetes • Pregnancy • History of acute pyelonephritis in the past year • Symptoms for seven or more days before seeking care • Broad-spectrum antimicrobial resistant uropathogen • Hospital acquired infection • Renal failure • Urinary tract obstruction • Presence of an indwelling urethral catheter, stent, nephrostomy tube or urinary diversion • Recent urinary tract instrumentation • Functional or anatomic abnormality of the urinary tract • History of urinary tract infection in childhood • Renal transplantation • Immunosuppression

15. UTI “Uncomplicated” in Men • Need culture to verify UTI • Likely need 7-14 days of treatment • Evaluate for predisposing factors • Evaluate for acute bacterial prostatitis • Evaluate for urethritis from GC/Chlamydia

16. Remember… • Antibiotics + OCP’s =

17. Acute Low Back Pain • 84% of adults have this at some time in their lives • 90% seeing primary care do not seek care after 3 months • Evaluation: History and Physical • Inspection of back and posture • Range of motion • Palpation of the spine • Straight leg raising (for patients with leg symptoms) • Neurologic assessment of L5 and S1 roots (for patients with leg symptoms) • Evaluation for malignancy (breast, prostate, lymph node exam) when persistent pain or history strongly suggests systemic disease

18. “Don’t I need an x-ray or something?” • Progressive neurological findings • Constitutional symptoms • History of traumatic onset • History of malignancy • Age ≥50 years • Infectious risk such as injection drug use, immunosuppression, indwelling urinary catheter, prolonged steroid use, skin or urinary tract infection • Osteoporosis • Consider >12 weeks of symptoms

19. Acute Low Back Pain - Treatment • Do not advise bed rest • NSAID or acetaminophen • Cyclobenzaprine • Short-term opioid if severe • Manipulation therapy • Severe radicular symptoms – consider epidural steroid injections

20. Foot and Ankle Pain • Ottawa ankle rules • Foot films: • Any pain in mid- foot zone and any: • Bone tenderness at C; • Bone tenderness at D; • Inability to bear weight both immediately and in the RAC • Ankle films: Any pain in malleolar zone and any: • Bone tenderness at A; • Bone tenderness at B; • Inability to bear weight both immediately and in the RAC

21. Syndesmotic injury – need Ortho External rotation stress test Squeeze test

22. Refer to Ortho for: • Fracture • Dislocation or subluxation • Syndesmosis injury • Tendon rupture • Wound penetrating into the joint • Uncertain diagnosis • Neurovascular compromise (distal findings of decreased sensation, motion, or circulation) require emergent evaluation.

23. Ankle injury treatment • RICE (rest, ice, compression, elevation) • Simple exercises as soon as possible

24. Vaginitis • Premenopausal: 90% bactvaginosis, candidiasis, trichomonas • Postmenopausal: also atrophic vaginitis

25. Vaginitis - Evaluation • Vaginal pH (Bactvaginosis >4.5, trich pH 5-6, candida 4-4.5) Vaginal wet prep, KOH (microscopy) + Whiff test • Cervical purulence – wet prep; GEN Probe

26. The Red Eye – Warning Signs • Reduction of visual acuity • Ciliary flush: A pattern of injection in which the redness is most pronounced in a ring at the limbus (the limbus is the transition zone between the cornea and the sclera) • Photophobia • Severe foreign body sensation that prevents the patient from keeping the eye open • Corneal opacity • Fixed pupil • Severe headache with nausea

27. Bacterial conjuctivitis • Purulent discharge throughout the day • Erythromycin ointment • Highly contagious – may return to work/school after 24 hours of topical antibiotics

28. References/Resources • CDC.gov/getsmart • choosingwisely.org • UpToDate