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Rebekah Byrne, MD-MPH Swedish Family Medicine-First Hill R3 Talks May 10, 2014

“So, I have a virus. Now what?” An evidence based, patient centered approach to the viral upper respiratory infection. Rebekah Byrne, MD-MPH Swedish Family Medicine-First Hill R3 Talks May 10, 2014. Objectives.

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Rebekah Byrne, MD-MPH Swedish Family Medicine-First Hill R3 Talks May 10, 2014

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  1. “So, I have a virus. Now what?”An evidence based, patient centered approach to the viral upper respiratory infection. Rebekah Byrne, MD-MPH Swedish Family Medicine-First Hill R3 Talks May 10, 2014

  2. Objectives • Understand the public health and economic impact of the viral upper respiratory infection (URI) • Be able to appropriately counsel your patient on the the viral URI. • Understand evidence based, patient centered approaches to prevention of the viral URI. • Understand evidence based, patient centered approaches to treating the viral URI.

  3. Case • A 42 year old, otherwise healthy, female presents to your office with complaints of scratchy throat, green rhinorrhea, and cough that wakes her up throughout the night. Her symptoms began 4 days ago. She missed work today and does not want to keep missing because she has a big project coming up. She asks you for a “z-pak” because her husband went to his physician and received this treatment. What do you tell her?

  4. “You have an upper respiratory tract infection (URI)” • A “benign,” self-limiting infection most often caused by a virus and characterized by cough, nasal congestion, rhinorrhea, and/or pharyngitis. No dominant symptom. • A clinical diagnosis, to be distinguished from: • Pneumonia: Likelihood of PNA <5% if no abnormal vital signs and normal chest exam. • Influenza, group A strep pharyngitis, acute bronchitis, acute sinusitis IDSA Clinical Practice Guidelines, 2012 Gonzales et al, Ann Intern Med 2001.

  5. “AKA Common Cold” • Humanity’s most frequent acute illness • Adults: average 2-4 episodes/yr • School aged children: average 4-10 episodes/yr • URI - 4th most common diagnosis at U.S. primary care visits, 25 million visits/yr CDC/NCHS. National ambulatory medical care survey: 2010 summary tables CDC http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf

  6. A not so benign illness • Based on telephone survey of 4,000 U.S. adults, 2000-01 • 40 million days lost from work or school per year in the U.S. Cost of viral URI/yr in $US Billions $40 Billion/yr Fendrick AM, The economic burden of non-influenza related viral respiratory tract infection in the United States. Arch Intern Med. 2003;163(4):487

  7. Counseling Patients • How important is it? • Patient satisfaction survey of 1160 primary care patients with viral URI diagnosis: Receiving patient education/reassurance more important than receiving antibiotics prescription (OR 10.6); for those with expectations for receiving antibiotics, counseling/reassurance was an equally important determinant of satisfaction as receiving an antibiotic (OR 4.7 vs 3.8). Welschen I, et al FamPrac. 2004. • How to do it?CDC Get Smart, NICE Guidelines • Identify and validate patient concerns; answer questions • Provide reassurance • Establish realistic expectations for duration of illness • Make a contingency plan • Provide patient education on antibiotic harm • Recommend specific symptomatic therapy

  8. Set Up Expectations • Ave duration of symptoms: 7-11 days, range 1-31 days

  9. “Call or return if you experience…” • Fever >102F lasting >2 days • “Double sickening;” Worsening of symptoms after day 5-6 • Persistent symptoms lasting >10 days • Cough >3 weeks • New symptoms: Facial pain, tooth pain, shortness of breath, coughing paroxysm, post-tussive emesis.

  10. “About those antibiotics…” • No evidence of benefit to warrant use of antibiotics in children or adults. Arroll et al. Cochrane 2013 • Risk of Harm: 2.62 RR • Delayed prescriptions? Spurling et al. Cochrane 2013 • No clinical difference for most symptoms • Antibiotic use: • Delayed Rx 32% • Immediate Rx 93% • No initial Rx 14% • No difference in patient satisfaction Delayed Rx vs no antibiotics (patient satisfaction 80%)

  11. At the end of the day, effective communication and appropriate care are more important than an antibiotic for patient satisfaction.

  12. Prevention of theviral URI

  13. “Hey doc, what about those herbal supplements I keep hearing about, will those help me from getting sick?”

  14. Prevention:Non-traditionalMethods

  15. Treatment of the Viral URI • Symptom Management • Nutrition supplements and herbal therapies

  16. Symptom:Discomfort

  17. Symptom: Cough

  18. Symptoms: Congestion, rhinorrhea

  19. Overall Symptom Severity & Duration

  20. Take Home Points • The viral URI is a self-limited infection but it has a huge impact. • Set up realistic expectations for your patient. • Do no harm. Antibiotics = harm • Prevent transmission: wash your hands with soap, often.

  21. Take Home Rx Symptomatic Treatment • Discomfort: NSAIDS, consider side effects. • Congestion, rhinorrhea: decongestants, intranasal ipratropium ($) • Cough: Inhaled ipratropium $; Honey 2.5-10 mg qHS Decreasing length of illness & overall symptom relief • Antihistamine + Decongestant • Zinc gluconate 23 mg lozenge q 2 hr; P. Sidoides likely beneficial.

  22. Thank you!Please see syllabus for supplemental materials and for resources.

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