RAC-KING IT – EVIDENCE
BASED STYLE
UIM 2015
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
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URI – “ LAST TIME I NEEDED AN
ANTIBIOTIC”
• Viral or Bacterial?
• Viral treatment – analgesics, nasal saline, fluid,
intranasal glucocorticoids
• Rhinosinusitis symptoms lasting ten or more days and
any of the following:
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High, persistent fever
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
Augmentin, bactrim, cephalosporins - doxycycline
PHARYNGITIS
• Centor Criteria:
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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
• 2 or fewer Centors: no culture, no treatment
• 3+ 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
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Upper airway cough syndrome
Asthma
Gastroesophageal refluxLaryngopharyngeal 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:
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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
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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
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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
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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
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“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 >4 weeks of symptoms and candidates for
invasive treatments
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ACUTE LOW BACK PAIN - TREATMENT
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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:
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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
External rotation stress test
Squeeze test
REFER TO ORTHO FOR:
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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
CILIARY FLUSH
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