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In an effort to do more clinical-type postings here, I'm going to give a quick run down of my approach to the various winter respiratory infections and what I do with them (and why). This is not set in stone, as we all have patients we know well enough to not fit any particular model. At the moment, this is also limited to adults since kids and fevers go together like peas and carrots - yes, I just re-watched Forrest Gump.
For my own sanity's sake, I've broken down the winter crud into several basic categories: URI, Sinus infection (bacterial v. viral), pharyngitis (strep v. viral), bronchitis, pneumonia, and flu. I approach my H&P based on these possibilities.
So a little background. The IDSA tells us that most rhinosinusitis is viral (98+%). There are 3 ways (really 2) to tell if a patient is in the 2%. Symptoms constant for 10+ days, double sickening, or fever/sinus tenderness/purulent drainage - IDSA says temp over 101.5, I usually go with the CDC definition of fever (100.4). Double sickening still involved fever, just after a brief convalescent period, so I don't usually give that its own category. Not all that evidenced based, but when patients hit triple digits they get antsy. I will also make exceptions to the "my spouse said I felt really hit" since apparently no one owns a thermometer anymore.
If you look into the evidence behind bronchitis, you'll see that about 90% of that is viral. The remaining 10% doesn't seem to actually improve with antibiotics anyway barring some sort of chronic lung disease.
For pharyngitis, rapid antigen testing for strep A has a great PPV, not so good on the negative side. Luckily, the Centor Criteria is the exact opposite. So, a negative rapid test and fewer than 3 of the Centor Criteria leave me pretty confident in a negative.
Flu and pneumonia can be tricky, and I'll admit to getting lots of negative x-rays in the winter. Generally speaking, fever + cough and dyspnea (dyspnea being the big one) with a negative flu buys you a chest x-ray. Also not evidenced based, but radiation exposure is miniscule and a CXR down the hall is $40 for film and read.
So for my approach: Cough alone rules out sinus, URI, and pharyngitis (naturally). No fever or dyspnea give you bronchitis. My go to regiment is Mucinex DM (patients like specifics), honey (surprisingly evidenced-based), and hot tea. I have my own spiced tea recipe that I let patients sample in the office - they love it. If they ask for a prescription, I inquire about tessalon. At this stage, most people have tried it and either love it or hate it. If love, I'll write for that all day long. If hate, I'll usually relent with either codeine or hydrocodone cough syrup - codeine if its a reported history of cough, hydrocodone if they hack up a lung in the office.
If you add fever, you're at the flu v. PNA stage. Just dyspnea, and I usually qualify that as out of breath walking in from the parking lot, and you've bought yourself a CXR. For flu, I'll offer tamiflu but explain that for healthy people its expensive and that I've never been that impressed with its efficacy. For PNA, I've been using a lot of doxycycline. My area has been seeing lots of tendon issues and c. diff from levaquin and zithromax is essentially useless for strep pneumo and h. flu here. Will sometimes use inhalers, but again not impressed with efficacy there.
Congestion takes us to URI v. Sinus infection. If no sinus tenderness to percussion, you're a URI. If you do have tenderness, you're sinus. Whether you get antibiotics depends on duration or fever. For URI/viral sinus, I go with Mucinex for cough, sudafed (real sudafed, not the PE crap - making a Breaking Bad joke if patient under 70), afrin if really bad (with a stern talking to about how to use it to avoid rebound congestion), and lots of hot tea/soup. If I go to antibiotics, regular augmentin is OK if your local strep pneumo resistance to penicillin is less than 10%. Greater than that and you have to go to augmentin XR. I also use a good bit of doxy here as well. Levaquin is reserved for the young-ish patient who saw the NP at CVS and was given amoxicillin last week that of course didn't help.
Sore throat as primary complaint buys most patients a rapid strep - they've come to expect it and its cheap (costs me $1.50 to buy). If positive, I still like Pen VK - free at the local grocery store, and best evidence outside of the IM Bicillin. If negative but still concerning, will send culture. If negative and note concerning for strep, viral and talk symptom care. I take a 3-pronged approach explaining that each one will help about 25%. First, OTC pain meds - don't care which one. Second, Chloraseptic spray - tastes awful, works great. Third, lots of ice cream and milkshakes. If throat looks really bad or patient has a really tough time of it (mentions really bad pain for instance), I have started using short courses of decadron - like 6mg daily for 3-4 days. I've had pretty good results with that.
So that's kinda my approach. I hope that helps the folks still in training, and I'd love to hear how others out in practice do things.
For my own sanity's sake, I've broken down the winter crud into several basic categories: URI, Sinus infection (bacterial v. viral), pharyngitis (strep v. viral), bronchitis, pneumonia, and flu. I approach my H&P based on these possibilities.
So a little background. The IDSA tells us that most rhinosinusitis is viral (98+%). There are 3 ways (really 2) to tell if a patient is in the 2%. Symptoms constant for 10+ days, double sickening, or fever/sinus tenderness/purulent drainage - IDSA says temp over 101.5, I usually go with the CDC definition of fever (100.4). Double sickening still involved fever, just after a brief convalescent period, so I don't usually give that its own category. Not all that evidenced based, but when patients hit triple digits they get antsy. I will also make exceptions to the "my spouse said I felt really hit" since apparently no one owns a thermometer anymore.
If you look into the evidence behind bronchitis, you'll see that about 90% of that is viral. The remaining 10% doesn't seem to actually improve with antibiotics anyway barring some sort of chronic lung disease.
For pharyngitis, rapid antigen testing for strep A has a great PPV, not so good on the negative side. Luckily, the Centor Criteria is the exact opposite. So, a negative rapid test and fewer than 3 of the Centor Criteria leave me pretty confident in a negative.
Flu and pneumonia can be tricky, and I'll admit to getting lots of negative x-rays in the winter. Generally speaking, fever + cough and dyspnea (dyspnea being the big one) with a negative flu buys you a chest x-ray. Also not evidenced based, but radiation exposure is miniscule and a CXR down the hall is $40 for film and read.
So for my approach: Cough alone rules out sinus, URI, and pharyngitis (naturally). No fever or dyspnea give you bronchitis. My go to regiment is Mucinex DM (patients like specifics), honey (surprisingly evidenced-based), and hot tea. I have my own spiced tea recipe that I let patients sample in the office - they love it. If they ask for a prescription, I inquire about tessalon. At this stage, most people have tried it and either love it or hate it. If love, I'll write for that all day long. If hate, I'll usually relent with either codeine or hydrocodone cough syrup - codeine if its a reported history of cough, hydrocodone if they hack up a lung in the office.
If you add fever, you're at the flu v. PNA stage. Just dyspnea, and I usually qualify that as out of breath walking in from the parking lot, and you've bought yourself a CXR. For flu, I'll offer tamiflu but explain that for healthy people its expensive and that I've never been that impressed with its efficacy. For PNA, I've been using a lot of doxycycline. My area has been seeing lots of tendon issues and c. diff from levaquin and zithromax is essentially useless for strep pneumo and h. flu here. Will sometimes use inhalers, but again not impressed with efficacy there.
Congestion takes us to URI v. Sinus infection. If no sinus tenderness to percussion, you're a URI. If you do have tenderness, you're sinus. Whether you get antibiotics depends on duration or fever. For URI/viral sinus, I go with Mucinex for cough, sudafed (real sudafed, not the PE crap - making a Breaking Bad joke if patient under 70), afrin if really bad (with a stern talking to about how to use it to avoid rebound congestion), and lots of hot tea/soup. If I go to antibiotics, regular augmentin is OK if your local strep pneumo resistance to penicillin is less than 10%. Greater than that and you have to go to augmentin XR. I also use a good bit of doxy here as well. Levaquin is reserved for the young-ish patient who saw the NP at CVS and was given amoxicillin last week that of course didn't help.
Sore throat as primary complaint buys most patients a rapid strep - they've come to expect it and its cheap (costs me $1.50 to buy). If positive, I still like Pen VK - free at the local grocery store, and best evidence outside of the IM Bicillin. If negative but still concerning, will send culture. If negative and note concerning for strep, viral and talk symptom care. I take a 3-pronged approach explaining that each one will help about 25%. First, OTC pain meds - don't care which one. Second, Chloraseptic spray - tastes awful, works great. Third, lots of ice cream and milkshakes. If throat looks really bad or patient has a really tough time of it (mentions really bad pain for instance), I have started using short courses of decadron - like 6mg daily for 3-4 days. I've had pretty good results with that.
So that's kinda my approach. I hope that helps the folks still in training, and I'd love to hear how others out in practice do things.
