1. Jacobi Ambulatory Care Service COLDS Matt Love

2. Jacobi Ambulatory 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

3. Jacobi Ambulatory Care Service Epidemiology September through May Spread by hand-to-hand contact and aerosols

4. Jacobi Ambulatory Care Service Microbiology Virus % of cases Rhinovirus30-40 Coronavirus10-15 RSV Influenza Parainfluenza Adenovirus Unkown25-40

5. Jacobi Ambulatory Care Service Pathogenesis ICAM Rhinosinusitis Histology of Nasal Epithelium is Normal Increased vascular permeability and secretions Components of Snot Role of PMNs, Histamine, Kinins, IL

6. Jacobi Ambulatory 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

7. Jacobi Ambulatory Care Service H & P SymptomFrequency Day Nasal 45 to 75% 1 - 2 Discharge Sneezing Obstruction Pharyngeal 35 to 50% 2 - 3 Sore Throat Scratch Throat Cough 40 to 80% 2 -14 Hoarse 15 to 30% 2 - 14 Constitutional 2 - 4 Feverish Myalgia Headache

8. Jacobi Ambulatory Care Service Consider Complications Bronchitis Sinusitis Otitis Media Pneumonia Bronchospasm

9. Jacobi Ambulatory Care Service THE TRUE BLUE FLU Epidemiology 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

10. Jacobi Ambulatory Care Service 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

11. Jacobi Ambulatory Care Service DIAGNOSIS OF INFLUENZA Are 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

12. Jacobi Ambulatory Care Service 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 Value86.8% Negative Predictive Value39.3% Sensitivity77.6% Specificity55.0% __________________________

13. Jacobi Ambulatory 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

14. Jacobi Ambulatory Care Service DIAGNOSIS OF INFLUENZA RAPID FLU TESTS

15. Jacobi Ambulatory Care Service INFLUENZA Treatment DrugTrade NameFlu TypeCostCaveat ____________________________________________________ AmantidineSymmetrelA9.83 Resistance Generic1.72 CNS RimantidineFlumadineA18.87 Resistance ZanamivirRelenzaA and B44.40 Bronchospasm OseltamivirTamifluA and B53.00 GI

16. Jacobi Ambulatory Care Service INFLUENZA Prophylaxis VACCINATE EXPOSURES LONGTERM CARE FACILITIES

17. Jacobi Ambulatory 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

18. Jacobi Ambulatory Care Service

19. Jacobi Ambulatory 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. a

20. Jacobi Ambulatory Care Service Patients’ Understanding of the Common Cold What Causes a Cold? Virus43.5% Virus and Bacteria41.9% Bacteria 7.9% Don’t Know 6.7% Antibiotics are helpful for colds Strongly Agree18.2% Agree26.1% Disagree17.2% Strongly Disagree31.4% Don’t know 7.1% aa

21. Jacobi Ambulatory Care Service 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

22. Jacobi Ambulatory Care Service 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

23. Jacobi Ambulatory 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%

24. Jacobi Ambulatory Care Service Symptomatic Treatment SymptomTreatments CongestionTopical Decongestant Oral Decongestant RhinorrheaAnticholinergic SneezingAntihistamine CoughSuppressant Tx for Rhinorrhea ConstitutionalAcetaminophen ASA, NSAID Sore ThroatGargles, Lozenges Analgesia a

25. Jacobi Ambulatory Care Service Remedies Zinc Gluconate Vitamin C Chicken Soup Vapors

26. Jacobi Ambulatory Care Service You’ve got the worst cold I’ve seen all day

27. Jacobi Ambulatory Care Service Are you miserable? You look miserable.

28. Jacobi Ambulatory Care Service I wish we had better treatments for bad colds

29. Jacobi Ambulatory Care Service but as you know there’s no cure yet

30. Jacobi Ambulatory Care Service Your cold comes from a viral infection.

31. Jacobi Ambulatory Care Service Un fortun ate ly,

32. Jacobi Ambulatory Care Service And furthermore,

33. Jacobi Ambulatory Care Service YOUR body will fight this off just like it’s always done.

34. Jacobi Ambulatory Care Service Your body’s immune system works best when you give it plenty of rest

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

36. Jacobi Ambulatory Care Service If it’s helping, keep taking the oil of newt

37. Jacobi Ambulatory Care Service If you get worse,

38. Jacobi Ambulatory Care Service I HOPE YOU FEEL BETTER SOON

39. Jacobi Ambulatory Care Service bye

40. Jacobi Ambulatory Care Service NO I AM NOT JUST GOING TO GIVE YOU THE ANTIBIOTICS

41. Jacobi Ambulatory Care Service

42. Jacobi Ambulatory 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