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JacobiAmbulatory Care Service
COLDS
Matt Love
JacobiAmbulatory Care Service
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
JacobiAmbulatory Care Service
Epidemiology
• September through May• Spread by hand-to-hand contact and aerosols
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Microbiology
Virus % of cases
Rhinovirus 30-40Coronavirus 10-15RSVInfluenzaParainfluenzaAdenovirusUnkown 25-40
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Pathogenesis
• ICAM• Rhinosinusitis• Histology of Nasal Epithelium is Normal• Increased vascular permeability and
secretions• Components of Snot• Role of PMNs, Histamine, Kinins, IL
JacobiAmbulatory Care Service
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
JacobiAmbulatory Care Service
H & P
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
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Consider Complications
• Bronchitis• Sinusitis• Otitis Media• Pneumonia• Bronchospasm
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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
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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
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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
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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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JacobiAmbulatory Care Service
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
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DIAGNOSIS OF INFLUENZA
RAPID FLU TESTS
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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
JacobiAmbulatory Care Service
INFLUENZA
Prophylaxis
• VACCINATE
• EXPOSURES
• LONGTERM CARE FACILITIES
JacobiAmbulatory Care Service
Approach to the common cold
• H & P• Diagnosis - consider flu, bacterial
complications, allergy, strep• Ascertain Expectations• Reassure (but don’t minimize)• Express sympathy• Educate• Offer symptomatic relief
JacobiAmbulatory Care Service
JacobiAmbulatory Care Service
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.
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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%
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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
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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
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JacobiAmbulatory Care Service
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%
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Symptomatic Treatment
Symptom Treatments
Congestion Topical DecongestantOral Decongestant
Rhinorrhea Anticholinergic
Sneezing Antihistamine
Cough SuppressantTx for Rhinorrhea
Constitutional AcetaminophenASA, NSAID
Sore Throat Gargles, LozengesAnalgesia
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Remedies
• Zinc Gluconate• Vitamin C• Chicken Soup• Vapors
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You’ve got the worst cold I’ve seen all day
JacobiAmbulatory Care Service
Are you miserable?You look miserable.
JacobiAmbulatory Care Service
I wish we had better treatments for bad colds
JacobiAmbulatory Care Service
but as you know
there’s no cure yet
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Your cold comes from a viral infection.
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Unfortunately,
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And furthermore,
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YOUR body will fight this off just like it’s always done.
JacobiAmbulatory Care Service
Your body’s immune system
works best when you give it plenty of rest
JacobiAmbulatory Care Service
In the meantime, let’s see if we can treat the symptoms so you’re not suffering so much.
JacobiAmbulatory Care Service
If it’s helping, keep taking the oil of newt
JacobiAmbulatory Care Service
If you get worse,
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I HOPE YOU FEEL BETTER SOON
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bye
JacobiAmbulatory Care Service
NO I AM NOT JUST GOING TO GIVE YOU THE ANTIBIOTICS
JacobiAmbulatory Care Service
JacobiAmbulatory Care Service
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