Transcript colds 2.ppt

COLDS
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
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Virus
Rhinovirus
Coronavirus
RSV
Influenza
Parainfluenza
Adenovirus
Unkown
% of cases
30-40
10-15
25-40
Pathogenesis
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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
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• H&P
• Diagnosis - consider complications, flu
allergy, strep
• Ascertain Expectations
• Reassure (but don’t minimize)
• Express sympathy
• Educate
• Offer symptomatic relief
H&P
Symptom
Nasal
Discharge
Sneezing
Obstruction
Pharyngeal
Sore Throat
Scratch Throat
Cough
Hoarse
Constitutional
Feverish
Myalgia
Headache
Frequency
Day
45 to 75%
1-2
35 to 50%
2-3
40 to 80%
15 to 30%
2 -14
2 - 14
2-4
Consider Complications
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Bronchitis
Sinusitis
Otitis Media
Pneumonia
Bronchospasm
THE TRUE BLUE FLU
Epidemiology
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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 FLU
Clinical 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 INFLUENZA
Are there pathognomonic symptoms?
Proportion of patients with symptom
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Symptom
Fever (> 37.8)
Feverishness
Cough
Nasal congestion
Weakness
Loss of Appetite
Sore Throat
Headache
Myalgia
• With flu
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68
•
90
•
93
•
91
•
94
•
92
•
84
•
91
•
94
Without flu
40
89
80
81
94
86
84
89
94
DIAGNOSIS OF INFLUENZA
Are 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 season
Positive Predictive Value
Negative Predictive Value
Sensitivity
Specificity
86.8%
39.3%
77.6%
55.0%
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
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Amantidine
Symmetrel
Generic
A
9.83
1.72
Resistance
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
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
Patients’ Understanding of the
Common Cold
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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
Antibiotics are helpful for colds
What Causes a Cold?
Virus
43.5%
Virus and Bacteria 41.9%
Bacteria
7.9%
Don’t Know
6.7%
Strongly Agree
Agree
Disagree
Strongly Disagree
Don’t know
18.2%
26.1%
17.2%
31.4%
7.1%
Factors Correlating with a Desire
for Antibiotics
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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
Congestion
Treatments
Topical Decongestant
Oral Decongestant
Rhinorrhea
Anticholinergic
Sneezing
Antihistamine
Cough
Suppressant
Tx for Rhinorrhea
Constitutional
Acetaminophen
ASA, NSAID
Gargles, Lozenges
Analgesia
Sore Throat
Remedies
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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
bye
NOT
NO I AM
JUST
GOING TO GIVE YOU THE
ANTIBIOTICS
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