A lecture for 3rd year med students about URI.

1. URI
Jonathan Ploudré, MD
unchart.com
December, 2011

2. Seriously, URI?
• Um, Who cares?
• It’s self-limiting…
• This isn’t even important enough to score a
chapter in my Pathology book

3. Primary Care
disruption
• November 2011: Wal-Mart has plans to go
into Primary Care. (npr.org)
• From 2007 to Now: 10x increase in retail
clinic visits. (advisory.com)

4. #FMRevolution
• FPs are just gatekeepers to proceduralists
• FPs are wasting their talents
• FPs will be replaced by mid-levels
• Or: FPs are the center of a modern, high-
quality, efficient health-care system.
URI is a perfect example of ‘wasting talent’ or being replaceable, right?

5. Is Dr. Ploudré an
Expert on URI?
500
375
250
125
0
URI Cough Sinusitis Pharyngitis ETD Strep Conjunctivitis Bronchitis AOM
I’ve diagnosed these things a lot in the past 3 years…

6. OK-plateau?
• Joshua Foer: How many of you are faster at
typing than you were a year ago?
• Autopilot or Deliberate Practice?
• I can diagnose and treat URI-related illness
1000x in the past few years but unless I’m
deliberately practicing, I may not be an expert.

7. Non Deliberate
Medicine
• In Med school/Residency everyone had an
‘Allegra’ Pen or ‘Claritin’ notepad.
• Non-sedating antihistamines cost $100/
month then.
• How did I get to be a 3rd year FP resident
before I learned nasal corticosteroids were
dramatically more effective than non-
sedating antihistamines?

8. Deliberate EBM
PICO
• Patient / Population / Problem (among
_____)
• Intervention / Exposure (does _____)
• Comparison (versus ______)
• Outcome (affect _______)
Keep asking questions. Check things you think you know.

9. 54yo Female presents with 5 day history of
illness. Initially started with a sore throat. On
the second day she developed a runny nose
and some nasal congestion. She’s just
developed a nonproductive cough.
Exam: Afebrile, Unremarkable.

10. URI

11. Among healthy adults with viral URI
does antibiotic treatment
vs watchful waiting
affect length of illness?

12. “Sure.” (55% of Patients)
J Gen Intern
Med
1999
“Oh, last time I got that 5 day prescription that works for 10 days. It was great.”

13. 2 prescriptions for antibiotics
(Respiratory/UTI) in primary care
results in measurable increase in
antibiotic resistance that can last as long
as 12 months.
BMJ 2010
We know antibiotics are ineffective. And potentially harmful.

14. Antibiotics:
Number Needed to Harm = ~16
Lancet, 2004
Not to mention population level issues like MRSA and VRE…

15. Overprescription

16. • OK, no antibiotics. Now what?

17. What works for URI
Use This: For This:
Fever, Sore Throat,
Acetaminophen
Aches
Fever, Sore Throat,
NSAIDs
Aches
dextromethorphan cough
pseudoephedrine congestion
antihistamines sneezing, sedation

18. What works for
Peds URI?
Use This: For This:
Fever, Sore Throat,
Acetaminophen
Aches
Fever, Sore Throat,
NSAIDs
Aches
antihistamines sedation
FDA in 2007: Oops. Pseudoephedrine can overdose kids.

19. Among healthy adults with viral URI
does guaifenisen
vs watchful waiting
affect impact of cough?

20. What doesn’t work
Guaifenisen for cough (except Smokers/COPD)
Antihistamines for rhinorrhea
phenylephrine (Sudafed PE)

21. Zinc for shortening
URI? Saline Gargle for
reducing URI
frequency
Probiotics for reducing URI frequency?
Echinacea for shortening URI
Vitamin C for
shortening URI

22. Zinc for shortening
URI? Saline Gargle for
reducing URI
frequency
Probiotics for reducing URI frequency?
Echinacea for shortening URI
Vitamin C for
shortening URI

23. Among patients with URI
does prescribing antibiotics
vs explaining why not to prescribe
affect length of the visit?

24. Maybe 0-1 minute longer visit.
Arch Pediatr
Adolesc Med,
2005. Clin Ther,
2003;

25. Explaining Inaction
“Viral” “I think it isn’t right”
“Resistance” “Microbiome”
“Natural” “Overused”
“Yeast Infection or Diarrhea” “I’m the Doctor”
“Doesn’t work” …

26. A tale of 2 doctors

27. 27yo Male presents with 10 day history of
illness. Initially started with a sore throat,
then runny nose then cough. Started to
improve until 3 days ago when he started to
develop purulent nasal discharge and mild
chills.
Exam: Afebrile, Unremarkable except facial
tenderness over the left maxilla.

28. Sinusitis

29. Among adults with classic sinusitis
does antibiotic treatment
vs watchful waiting
affect length of illness?

30. Yes. But NNT = 8. No symptom clearly
separates bacterial from viral sinusitis.
(Green discharge, ie, doesn’t matter.)
Without Purulent Discharge NNT = 15.
(Remember: NNH = 16.)
Prevalencee studies: ~97% of sinusitis is
not bacterial. No treatment in some
studies for up to 3 week unless febrile.
Lancet, 2008

31. Sinus Rinse?

32. Effective for Chronic Sinusitis
Probably effective for URI, Allergic
Rhinitis, Irritant Rhinitis.
Ploudre Opinion: Whoa. That
seriously gets snot out of my nose. But
50% of patients dislike it.
Am Fam Phys,
2009

33. Among adults with hx of recurrent sinusitis
does adding nasal corticosteroids to abx
vs antibiotics alone
affect length of illness?

34. Yes 93% vs 73% clinical success rate.
Median of 6 days vs 9 days.
“If you take this nasal spray, you’ll
probably get better about 3 days earlier.”
JAMA, 2001
I seriously just looked this up in PubMed in ~ 90 seconds.

35. 43 yo Female presents with cough. Illness
started with a mild runny nose but cough
quickly became main issue. Now 16 days into
the illness with nonproductive cough. Cough
disrupts sleep now.
Exam: 98% pulse ox, afebrile. Otherwise
unremarkable.

36. Bronchitis

37. Among adults with bronchitis
does azithromycin
vs Vitamin C
affect length of illness?

38. No.
Lancet, 2002

39. rld Ethical Practice
Wo
ie re
Prem
E= E 3
Ethical = Evidenced x
Economic x Etiquette

40. Ethical Azithromycin?
Well:
It doesn’t really work
It used to cost $75
But patients love it’s tolerability and
convenience.
Contrast: Bronchitis, Smokers with Bronchitis, Smoker with COPD exacerbation

41. Bronchitis Etiquette
“Bronchitis” vs “Chest Cold”
26% vs 13% of Patients disatisfied about
not getting antibiotics.
J. Am Board Fam
Practice, 2005

42. See One,
Do One,
Teach One.
Just this week I learned why I always use Nystatin for newborn thrush.

43. Is URI a waste of time?
Yes: It might take a good programmer a
week to create a good statistical prediction
rule to outperform most doctors in
providing evidence-based care.
Yes: Another case of the US spending more
than anyone with little to show for it.

44. Is URI a waste of time?
No: URI visits are a chance to ‘calibrate
sensors’ for patients through education.
No: URI visits can be used to reduce our
dangerous habit of overprescription of
antibiotics.
No: URI is a source of rapport and a deeper
doctor-patient relationship.

45. ?