4. EVIDENCE-
BASED
MANAGEMENT
RULE #1 – Determine sick vs not-sick
RULE #2 – Vitals are vital
RULE #3 – Risk stratify everybody
PATIENT
LR HR
CC
LR
HR 43
21
RIGHT THING
TITLE
TRIVIA
INTRO
GOALS
EBM
CASE
URI
URI PROBLEM
5. EVIDENCE-
BASED
MANAGEMENT
RULE #1 – Determine sick vs not-sick
RULE #2 – Vitals are vital
RULE #3 – Risk stratify everybody
RULE #4 – Go Early
Aggressive
Symptom
Treatment
RIGHT THING
TITLE
TRIVIA
INTRO
GOALS
EBM
CASE
URI
URI PROBLEM
7. EBM FOR URI
EVIDENCE-
BASED
MANAGEMENT
1. The URI problem
2. Abx management of:
• Otitis media
• Sinusitis
• Pharyngitis
• Bronchitis
TRIVIA
RIGHT THING
TRIVIA
GOALS
EBM
CASE
URI
URI PROBLEM
12. EVIDENCE-
BASED
MANAGEMENT
The more systems involved
in an illness, the more likely
that illness is caused by a
virus.
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
URI
URI PROBLEM
13. EVIDENCE-
BASED
MANAGEMENT
• Very difficulty to study
• Potential bacteria = 7%
J Clin Micro. 1998;36(2):539-42
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
URI
URI PROBLEM
14. EVIDENCE-
BASED
MANAGEMENT
The “common cold”
• Nearly always viral
• More than 200 subtypes
Sexton DJ, McClain MT. The common cold in adults: Diagnosis and clinical features. UpToDate.
http://www.uptodate.com.hsl-ezproxy.ucdenver.edu. Accessed 9/24/2012.
Rhino Echo Paramyxo Entero Adeno Coxsackie
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
GOALS
URI
URI PROBLEM
15. EVIDENCE-
BASED
MANAGEMENT
• Most common illness
• 500 million / year (US)
• Incidence: 2-3/adult/year
• Direct cost: $17 billion
• Indirect cost: $22.5 billion
• Common CC in EDs / UCCs
Kirkpatrick GL. The common cold. Prim Care. 1996;23(4):657
Fendrick AM, Monto AS, Nightengale B, Sarnes M. The economic burden of non-influenza-related viral
respiratory tract infection in the United States. Arch Intern Med. 2003;163(4):487.
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
16. EVIDENCE-
BASED
MANAGEMENT
Mainous AG 3rd. Hueston WJ. Clark JR. Antibiotics and upper respiratory infection: Do some folks think
there is a cure for the common cold? J of Fam Pract. 1996;42(4):357-61.
• Doctor visit = antibiotics
• 60% are prescribed antibiotic
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
17. EVIDENCE-
BASED
MANAGEMENT
Gonzales R, Bartlett JG, et al. Principles of Appropriate Antibiotic Use for Treatment of
Nonspecific Upper Respiratory Tract Infections in Adults: Background Intern Med.
2001;134:490-494.
• 2nd leading
dx for Abx
• 10-20% all
Abx Rx in US
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TRIVIA
URI
URI PROBLEM
TREATMENT
21. COMPLICATIONS
EVIDENCE-
BASED
MANAGEMENT
“A physician who merely spreads
an array of vendibles in front of
the patient and then says, „Go
ahead and choose, it‟s your life‟
does not warrant the still
distinguished title of doctor.”
Franz Ingelfinger, M.D.
Editor, NEJM
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
URI
URI PROBLEM
TREATMENT
22. RECS
EVIDENCE-
BASED
MANAGEMENT
This attending is a part-owner in
The Barkley, a luxury pet hotel and
spa in Los Angeles.
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
URI PROBLEM
TREATMENT
25. EVIDENCE-
BASED
MANAGEMENT
Finding the best evidence:
URI
OTITIS SINUSITIS PHARYNGITIS BRONCHITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
30. EVIDENCE-
BASED
MANAGEMENT
• Nearly always viral
• Antibiotics are useless
• “Purulent” secretions common
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TRIVIA
RIGHT THING
TREATMENT
35. EVIDENCE-
BASED
MANAGEMENT
• >80% of children
• Incidence drops after age 7
• Adult incidence only 0.25%
Brownlee RC, DeLoache WR, Cowan CC, Jackson HP. Otitis media in children: Incidence, treatment and
prognosis in pediatric practice. J Pediatr. 1969; 75:636.
Schwartz LE, Brown RB. Purulent otitis media in adults. Arch Int Med. 1992;152(11):2301-4.
DOGMA
SINUSITIS
TRIVIA
RECS
COMPLICATIONS
OTITIS
TRIVIA
EBM FOR URI
TREATMENT
50. EVIDENCE-
BASED
MANAGEMENT
Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute
bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72
• Historical featuresTRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
51. EVIDENCE-
BASED
MANAGEMENT
• Historical features
• Physical exam
Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute
bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
52. EVIDENCE-
BASED
MANAGEMENT
Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I.
Evaluation. Am Fam Physician. 2004 Nov 1;70(9):1685-92.
• Historical features
• Physical exam
• Purulence
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
53. EVIDENCE-
BASED
MANAGEMENT
Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic
study of the common cold. N Engl J Med. 1994;330(1):25
• Historical features
• Physical exam
• Purulence
• Radiology
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
SINUSITIS
TRIVIA
EBM
55. STREP
EVIDENCE-
BASED
MANAGEMENT
• Antibiotics – >80%!!!
Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for
acute rhinosinusitis in adults: background. Centers for Disease Control and
Prevention. Annals of Emergency Medicine. 2001;37(6):703-10
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
DOGMA
EBM
56. TRIVIA
EVIDENCE-
BASED
MANAGEMENT
Systematic Review
Williams JW Jr, Aguilar C, Makela M, et al. Antibiotic therapy for acute sinusitis: a
systematic literature review. In: Douglas R, et al., eds. Acute Respiratory Infections Module
of The Cochrane Database of Systematic Reviews. The Cochrane Library. 1997.
ABX
47% at 10-14d
81% Cure
No ABX
32% at 10-14d
66% Cure
NNT = 7
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
EBM
57. EVIDENCE-
BASED
MANAGEMENT
Stalman W, van Essen GA, et al. Br J Gen Pract. 1997;47:794-9
Lancet. 1997;349:683-7
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
PROBLEM
WARNING
EBM
61. RECS
EVIDENCE-
BASED
MANAGEMENT
Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute
sinusitis in adults. Ann Int Med. 2001;134(6):495-97
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
EBM
62. EVIDENCE-
BASED
MANAGEMENT
SINCE:
• Most ARS is viral
• Bacterial/viral cannot be
differentiated
• Most ABRS improves without Tx
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
EBM
63. EVIDENCE-
BASED
MANAGEMENT
RECOMMENDED:
• Symptomatic Tx and reassurance
• Pain medication
• Decongestants
• Abx only for severe symptoms
• Cover for strep and haemophilus
• Sx must be present >7 days
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
RECS
SUMMARY
EBM
72. EVIDENCE-
BASED
MANAGEMENT
Rheumatic Fever:
• RF 60-fold less common now
• 1954: NNT = 63
• 2012: NNT = 3000-4000
Catanzaro FJ, Stetson CA, et al. The role of the streptococcus in the pathogenesis of
rheumatic fever. Am J Med. 1954;17:749-56.
Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Cochrane
Review). In: The Cochrane Library, Issue 3, 1999. Oxford
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
73. EVIDENCE-
BASED
MANAGEMENT
Post-streptoccocal G.N.:
• No evidence that Abx help
• Extremely rare
Goslings WR, et al. Attack rates of streptococcal pharyngitis, rheumatic fever and
glomerulonephritis in the general population. N Engl J Med. 1963;268:687-94.
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
74. EVIDENCE-
BASED
MANAGEMENT
Post-streptoccocal G.N.:
• No evidence that Abx help
Peritonsillar Abscess
• 56% - abscess already present
• Only 25% PTAs are +GABHS
Webb KH, et al. Use of a high-sensitivity rapid strep test without culture confirmation of
negative results: 2 years‟ experience. J Fam Pract. 2000;49:34-8
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
75. EVIDENCE-
BASED
MANAGEMENT
Prevention of transmission:
• Small effect in schools
• Unknown in adults
Krober MS, Bass JW, Michels GN. Streptococcal pharyngitis. Placebo-controlled double-
blind evaluation of clinical response to penicillin therapy. JAMA. 1985;253:1271-4.
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
76. EVIDENCE-
BASED
MANAGEMENT
Prevention of transmission:
• Small effect in schools
Relief of symptoms:
• Hastens relief by 1 day
• Sx duration r/t satisfaction
Little P, Williamson I, Warner G, et al. Open randomised trial of prescribing
strategies in managing sore throat. BMJ.1997;314:722-7
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
STREP
PHARYNGITIS
TRIVIA
83. EVIDENCE-
BASED
MANAGEMENT
1. 10% pharyngitis is GABHS
2. Abx only for GABHS
3. Use 1 of 3 strategies
4. Culture should be only
for surveillance
END
SUMMARY
TRIVIA
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
84. EVIDENCE-
BASED
MANAGEMENT
3. Use 1 of 3 strategies:
A. 2-4 Centor criteria -
• Rapid antigen test
• Treat only positives
END
SUMMARY
TRIVIA
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
85. EVIDENCE-
BASED
MANAGEMENT
3. Use 1 of 3 strategies:
B. 2-3 Centor criteria -
• Rapid antigen test
• Treat positives
• 4 Centor criteria - treat
END
SUMMARY
TRIVIA
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
86. EVIDENCE-
BASED
MANAGEMENT
3. Use 1 of 3 strategies:
C. 3-4 Centor criteria - treat
• Don‟t use any testing
END
SUMMARY
TRIVIA
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
TRIVIA
90. EVIDENCE-
BASED
MANAGEMENT
• Incidence 5%/year
• Acute = 3 weeks
• As opposed to URI:
90% present for eval
Gonzales R, Wilson A, et al. What‟s in a name? Public knowledge, attitudes, and
experiences with antibiotic use for acute bronchitis. Am J Med. 2000;108:83-5
END
SUMMARY
TRIVIA
RECS
EVALUATION
BRONCHITIS
RECS
CENTOR
91. EVIDENCE-
BASED
MANAGEMENT
Metlay JP, Kapoor WN, Fine MJ. Does this patient have community acquired pneumonia?
Diagnosing pneumonia by history and physical examination. JAMA. 1997;278:1440-5.
CXR unnecessary if:
• Vitals normal
• HR < 100, RR < 24, T < 38
• No abnormal breath sounds
• Assymetric or focal
END
SUMMARY
TRIVIA
RECS
EVALUATION
BRONCHITIS
RECS
92. EVIDENCE-
BASED
MANAGEMENT
Ralph Gonzales, Paul H Barrett, Jr., John F Steiner. The Relation Between Purulent
Manifestations and Antibiotic Treatment of Upper Respiratory Tract Infections
J Gen Intern Med. 1999 March; 14(3): 151–156.
• OR 0.25 for bacterial cause
• OR 4.8 for Abx prescription
END
SUMMARY
TRIVIA
RECS
EVALUATION
BRONCHITIS
RECS
96. EVIDENCE-
BASED
MANAGEMENT
1. URIs and their component
illnesses are usually viral.
2. Even when complicated by
bacterial infections antibiotics
are rarely necessary.END
SUMMARY
TRIVIA
RECS
97. EVIDENCE-
BASED
MANAGEMENT
3. Make antibiotic decisions based
on the most prominent feature.
4. The default should be no
antibiotics unless overwhelming
evidence of bacterial infection.
5. Go E.A.S.T.
END
SUMMARY
TRIVIA
RECS
So, you walk into a teaching shift in the main ED. You start scanning the board for interesting cases you could see with the medical student and this is what jumps out at you. You think to yourself, “This is gonna be good!” So you scroll through the triage info and this is what you find.
So, you walk into a teaching shift in the main ED. You start scanning the board for interesting cases you could see with the medical student and this is what jumps out at you. You think to yourself, “This is gonna be good!” So you scroll through the triage info and this is what you find.
So, you walk into a teaching shift in the main ED. You start scanning the board for interesting cases you could see with the medical student and this is what jumps out at you. You think to yourself, “This is gonna be good!” So you scroll through the triage info and this is what you find.
So, you walk into a teaching shift in the main ED. You start scanning the board for interesting cases you could see with the medical student and this is what jumps out at you. You think to yourself, “This is gonna be good!” So you scroll through the triage info and this is what you find.
Which brings up an important evidence-based medicine principle: If you are going to practice safe reflexive care (ie I see X therefore I do Y with very little thought) you have to know what the literature says ahead of time. If you don’t want to think in the department, you have to have already thought about the scenario, in detail, before.
First, we’re going to talk about the URI problem and talk briefly about a diagnostic approach to URIs. Second, we’re going to focus on current best evidence regarding antibiotic management of…
Third we’ll focus on some specific evidence-based recommendation. And finally, the return of beer trivia.
Defining the syndrome that we all refer to as URI is really difficult. Although I’m going to use that term for the rest of the lecture, it probably is not a very good term to use. URI can refer to any or all of the following symptoms… and you could probably throw in headache, sneezing and sometimes vomiting/diarrhea.
Which brings up an important (but as far as I know, non-evidence based) principle that… Every viral illness includes a period of viremia – therefore multiple systems involved. If a bacterial illness involves a period of bacteremia, expect that pt to be sick.
One of the problems is that due to the poor definition for URI, it is a very difficult entity to study. In the largest study of the etiology of the common cold, a potential causative organism was only isolated in 7% of patients. Keep in mind that many of these may have only been colonizations and not the direct cause of the syndrome.
So, at least with the syndrome that we define as “common cold” it appears that nearly all cases are viral.
So we do we even care about the common cold? I mean we went into EM to take care of STEMIs and sepsis and gunshot wounds right? Well, part of the reason we need to know about it is because you are going to see a lot of it in your career.
The other reason to know the best evidence on managing the common cold is to avoid the other URI problem we are dealing with. Doctors continue to prescribe antibiotics for URIs. Paper after paper has documented the frequency of this practice. Currently, it is believed that almost 60% of people who present to a doctor for the common cold will be prescribed antibiotics.
And this is what pts want. Symptomatic treatment really doesn’t work that well and pts don’t really understand the arguments against antibiotics.
And it’s not hard to see how antibiotics happen. A lot of times at work we feel a little like this island where the combined pressures of pt expectations, fear of liability, easing the pt interaction, moving fast and pt satisfaction lead to the easiest solution which is hand them a prescription for antibiotics.
But convenient does not always mean appropriate, right?
Let me encourage you to do the right thing. I love this quote from the former editor of the New England Journal… It’s not a buffet line, right?
Well, you might say, “I’ve heard you say that we should not waste time…” for instance, should we be recommending ice for sprains. Because a non-surgical sprain is a self-limited condition (regardless of what we do for it) I choose not to spend my time looking up this data. You might say the same thing about URIs. Since it is a self-limited condition, no matter what we do, why waste our time looking at the data with regards to antibiotics. Hopefully as we go through some of the evidence, I’ll be able to convince you that it does, in fact, matter.
Since URI is such a broad and poorly defined syndrome, finding any good evidence on treatment is difficult. In order to find any high-level evidence, it has to be broken down into the separate components that make up the syndrome.
For each of these entities, you could subdivide into chronic, acute and allergic etiologies. Suffice it to say that chronic and allergic forms are almost never emergencies, therefore we’re not going to talk about those today. We’ll focus the evidence on the acute form.
Back in 2001, some pretty heavy hitters in medicine formed a task force to review the current best evidence on managing URI. I don’t know why but I had never heard of the papers that this group produced until I started doing literature review for this talk. I don’t know why that is (maybe because URI is boring to most of us) but the result papers from this task force should be required reading for all EM and primary care doctors. Somehow this information seems to have not influenced the practice behaviors of most doctors in this country.
Although they never came right out and said it. This task force essentially advocated the idea of focusing on the most prominent feature of the patient’s URI and making management decisions based on that rather than “URI” in general. They produced the following four papers which were published in AIM and reproduced in AEM and AFP.
Well, you might say, “I’ve heard you say that we should not waste time…” for instance, should we be recommending ice for sprains. Because a non-surgical sprain is a self-limited condition (regardless of what we do for it) I choose not to spend my time looking up this data. You might say the same thing about URIs. Since it is a self-limited condition, no matter what we do, why waste our time looking at the data with regards to antibiotics. Hopefully as we go through some of the evidence, I’ll be able to convince you that it does, in fact, matter.
Just a simple review of basic anatomy and pathophysiology… The common precipitating factor in nearly all cases of otiris is eustachian tube dysfunction. This usually occurs as a result of viral infection (URI) or allergy. Lack of aeration and drainage leads to a closed, warm, moist compartment and bacteria can infect.
Just a simple review of basic anatomy and pathophysiology… The common precipitating factor in nearly all cases of otiris is eustachian tube dysfunction. This usually occurs as a result of viral infection (URI) or allergy. Lack of aeration and drainage leads to a closed, warm, moist compartment and bacteria can infect.
Now most of us could make the diagnosis of purulent (or bacterial) AOM if we saw this TM or that TM. The problem is, what do we do with this one or this one or this one??
Complications include… and these are the real reasons to treat with antibiotics, but they are extremely rare.
There is very little high’level evidence on treating AOM in the adult population. Now both the AAP and AAFP have come out with guidelines in 2004 stating that observation, even for purulent otitis, is an appropriate option. This recommendation is based on the following data…
This is meta-analysis data from dozens of studies over 30 years. Take a look at a few things… If you look at clinical resolution at 7 days, the NNT with antibiotics is 8. If you look here at antibiotic induced diarrhea or vomiting, the NNH with antibiotics is 6.
But we all know that adults are not just big kids. To me, one of the biggest differences between the two is that adults can go back to the doctor if they are feeling worse, whereas children cannot. But what does the adult literature say?
As I mentioned, unfortunately there is no data on withholding antibiotics from adults with AOM. The next best thing is to look at the microbiology of AOM and make some inferences about treatment.
Well, what about those dangerous complications of AOM?? They are extremely rare. This study in Sweden found less than 10 cases ofmastoiditis yearly and no increase in incidence after their new recommendations not to treat otitis with antibiotics. If you look at adults only you see that over a 10 year period, there were only 3 cases of mastoiditis and 2/3 had had previous surgery of the temporal bone.
Similar results in Finland where they looked at all intratemporal and extratemporal complications. Again, less than 10/year.
Sinusitis is defined as inflammation of the paranasal sinuses and airspaces of the face due to infection, allergy or other inflammation. Acute sinusitis refers to these symptoms lasting less than 4 weeks. Subacute lasts from 4-12 weeks and chronic is sinusitis lasting greater than 12 weeks.
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Similar results in Finland where they looked at all intratemporal and extratemporal complications
There are 27 million visits/year to US EDs for sore throat. Probably hundreds of millions of visits to all ambulatory environments. The differential for sore throat is actually quite large. Before we get to the discussion of pharyngitis, let’s just go through a few of the other conditions you should be aware of when a pt c/o ST.
Once you have established that you are dealing with pharyngitis and not another cause of sore throat, the first step is to determine whether it is exudative or non-exudative.
Exudative pharyngitis is not always strep. Consider…
There are 27 million visits/year to US EDs for sore throat. Probably hundreds of millions of visits to all ambulatory environments. The differential for sore throat is actually quite large. Before we get to the discussion of pharyngitis, let’s just go through a few of the other conditions you should be aware of when a pt c/o ST.
Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
A few RCTs have shown that abx reduce sx duration by about 1 day. More recently studies have shown that pt report of sx is largely related to the pt’s satisfaction with the doctors treatment strategy.
A few RCTs have shown that abx reduce sx duration by about 1 day. More recently studies have shown that pt report of sx is largely related to the pt’s satisfaction with the doctors treatment strategy.
Once you have established that you are dealing with pharyngitis and not another entity, the goal has always been to identify strep pharyngitis.
Post-strep sequelae
DOGMA
Similar results in Finland where they looked at all intratemporal and extratemporal complications
Of those that present for evaluation of cough in the ambulatory setting, 70% are bronchitis, the next most common dx are asthma 6% and pneumonia 5%.
I was surprised by this but there is actually fairly robust data regarding when xray is needed for cough. There have been many attempts to develop clinical prediction rules but they all basically boil down to this.
Notably absent from all rules is the presence of “purulent” sputum which has been shown to be present in pneumonia, bacterial and viral bronchitis as well as sinusitis, common cold.