U I M 2 0 1 3

RAC-KING IT – EVIDENCE BASED STYLE

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

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

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

PHARYNGITIS

• Fewer than 2 Centors: no culture, no treatment• 2+ Centors: rapid strep/culture and treat only if

positive• Penicillin

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

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

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)

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

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)

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)

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!)

UTI VS PYLEONEPHRITIS

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

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

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

REMEMBER…

• Antibiotics + OCP’s =

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

“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

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

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

SYNDESMOTIC INJURY – NEED ORTHO

Squeeze test

External rotation stress test

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.

ANKLE INJURY TREATMENT

• RICE (rest, ice, compression, elevation)• Simple exercises as soon as possible

VAGINITIS

• Premenopausal: 90% bact vaginosis, candidiasis, trichomonas• Postmenopausal: also atrophic vaginitis

VAGINITIS - EVALUATION

• Vaginal pH (Bact vaginosis >4.5, trich pH 5-6, candida 4-4.5) Vaginal wet prep, KOH (microscopy) + Whiff test • Cervical purulence – wet prep; GEN Probe

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

BACTERIAL CONJUCTIVITIS

• Purulent discharge throughout the day• Erythromycin ointment• Highly contagious – may return to work/school

after 24 hours of topical antibiotics

REFERENCES/RESOURCES

• CDC.gov/getsmart• choosingwisely.org• UpToDate