Jacobi Ambulatory Care Service COLDS Matt Love. Jacobi Ambulatory Care Service The COMMON Cold #1...

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JacobiAmbulatory Care Service

Matt Love

The COMMON Cold

• #1 REASON for visits to physicians, #3 for internists

• 27 million physician visits per year• 23 million days of work missed• Average adult has 2-4 colds per year• $3 billion spent per year on OTC remedies

Epidemiology

• September through May• Spread by hand-to-hand contact and aerosols

Microbiology

Virus % of cases

Rhinovirus 30-40Coronavirus 10-15RSVInfluenzaParainfluenzaAdenovirusUnkown 25-40

Pathogenesis

• ICAM• Rhinosinusitis• Histology of Nasal Epithelium is Normal• Increased vascular permeability and

secretions• Components of Snot• Role of PMNs, Histamine, Kinins, IL

Approach to the common cold

• H & P• Diagnosis - consider complications, flu allergy,

strep• Ascertain Expectations• Reassure (but don’t minimize)• Express sympathy• Educate• Offer symptomatic relief

Symptom Frequency DayNasal 45 to 75% 1 - 2 Discharge Sneezing ObstructionPharyngeal 35 to 50% 2 - 3 Sore Throat Scratch ThroatCough 40 to 80% 2 -14 Hoarse 15 to 30% 2 - 14Constitutional 2 - 4 Feverish Myalgia Headache

Consider Complications

• Bronchitis• Sinusitis• Otitis Media• Pneumonia• Bronchospasm

THE TRUE BLUE FLUEpidemiology

• Usually peaks in January or later• 20,000 deaths in a typical epidemic season• 110,000 hospitalizations• 10%-20% of population infected during typical

season• When flu epidemic in region, high percentage

of those with ILI have flu

THE TRUE BLUE FLUClinical Presentation

• Classic Flu - sudden onset prostration, high fever, nasal stuffiness, sore throat, myalgia, cough and headache

• Study Flu - usually fever + 2 symptoms• Illness resolves over four to five days• Cough, fatigue, malaise can linger 2-3 weeks• Complications - bacterial tracheobronchitis,

sinsusitis, pneumonia

DIAGNOSIS OF INFLUENZAAre there pathognomonic symptoms?

Proportion of patients with symptom

Symptom

• Fever (> 37.8)• Feverishness• Cough• Nasal congestion• Weakness• Loss of Appetite• Sore Throat• Headache• Myalgia

With flu Without flu

• 68 40• 90 89• 93 80• 91 81• 94 94• 92 86• 84 84• 91 89• 94 94

DIAGNOSIS OF INFLUENZAAre there pathognomonic symptoms?

USE OF A CASE DEFINITION AS A DIAGNOSTIC TOOL

100 patients with a flu-like illness: T > 37.8 plus 2 of 4: cough, myalgia, sore throat, headache

Case Definition: T > 38 + cough during flu seasonPositive Predictive Value 86.8%Negative Predictive Value 39.3%Sensitivity 77.6%Specificity 55.0%

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DIAGNOSIS OF INFLUENZA INFLUENZA SURVEILLANCE\

www.cdc.gov

• WHO - worldwide tracking of drift and shift• CDC, Influenza Branch

– National Respiratory and Enteric Virus Surveillance System

– 122 Cities Mortality Reporting System– State and Territorial Epidemiologists Reports– US Influenza Sentinel Physicians Surveillance

Network

DIAGNOSIS OF INFLUENZA

RAPID FLU TESTS

INFLUENZA

Treatment Drug Trade Name Flu Type Cost Caveat____________________________________________________

Amantidine Symmetrel A 9.83 ResistanceGeneric 1.72 CNS

Rimantidine Flumadine A 18.87 Resistance

Zanamivir Relenza A and B 44.40 Bronchospasm

Oseltamivir Tamiflu A and B 53.00 GI

INFLUENZA

Prophylaxis

• VACCINATE

• EXPOSURES

• LONGTERM CARE FACILITIES

• H & P• Diagnosis - consider flu, bacterial

complications, allergy, strep• Ascertain Expectations• Reassure (but don’t minimize)• Express sympathy• Educate• Offer symptomatic relief

Patients’ Understanding of the Common Cold

* 87% of people do not seek care for their colds* In a survey of young adults 94% said it was not necessary to go to a doctor for a cold.

On the other hand* Of patients in a clinic for other reasons, 61% said they would seek care for 5days rhinorrhea, cough, sore throat; if the discharge were discolored, 79% would seek care. * 87% of a sample in England thought antibiotics were beneficial for a cold.

Patients’ Understanding of the Common Cold

What Causes a Cold?

Virus 43.5%

Virus and Bacteria 41.9%

Bacteria 7.9%

Don’t Know 6.7%

Antibiotics are helpful for colds

Strongly Agree 18.2%Agree 26.1%Disagree 17.2%Strongly Disagree 31.4%Don’t know 7.1%

Factors Correlating with a Desire for Antibiotics

• Previous Rx for Antibiotic for URI• Belief they work• Purulent secretions• Medicaid• From a country where abx are OTC

Why not give antibiotics?

Biggest Risk Factor for developing resistant S.pneumonia is previous exposure to abx

Good studies show that when overall antibiotic prescribing is reduced, the prevalence of resistant strains drops.

About 30% of all the antibiotics prescribed in the US are for outpatient colds. In many studies, patients with clear cut colds are Rxed abx 50-60% of the time.

They don’t work

A Multidimensional Intervention to Reducing Rxs For Antibiotics

• For “Bronchitis”• Preliminary study found that clinicians code

according to Rx given, not symptoms. The dx of “chest cold” rather than “bronchitis” lowered expectations for abx

• Patient and clinician education• Reduced Rxs for bronchitis from 74% to 48%

Symptomatic Treatment

Symptom Treatments

Congestion Topical DecongestantOral Decongestant

Rhinorrhea Anticholinergic

Sneezing Antihistamine

Cough SuppressantTx for Rhinorrhea

Constitutional AcetaminophenASA, NSAID

Sore Throat Gargles, LozengesAnalgesia

Remedies

• Zinc Gluconate• Vitamin C• Chicken Soup• Vapors

You’ve got the worst cold I’ve seen all day

Are you miserable?You look miserable.

I wish we had better treatments for bad colds

but as you know

there’s no cure yet

Your cold comes from a viral infection.

Unfortunately,

And furthermore,

YOUR body will fight this off just like it’s always done.

Your body’s immune system

works best when you give it plenty of rest

In the meantime, let’s see if we can treat the symptoms so you’re not suffering so much.

If it’s helping, keep taking the oil of newt

If you get worse,

I HOPE YOU FEEL BETTER SOON

NO I AM NOT JUST GOING TO GIVE YOU THE ANTIBIOTICS

• H & P• Diagnosis - consider complications, flu allergy,

strep• Ascertain Expectations• Reassure (but don’t minimize)• Express sympathy• Educate• Offer symptomatic relief

Jacobi Ambulatory Care Service COLDS Matt Love. Jacobi Ambulatory Care Service The COMMON Cold #1...

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