Transcript Community Acquired Respiratory Tract Infections

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Program:
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Dr. Anthony Ciavarella MD
51st Annual Scientific Assembly, OCFP
Community Acquired Respiratory Tract Infections:
The usual suspects
– Speakers Bureau/Honoraria: Merck Frosst, Pfizer, Bayer.
– Consulting Fees:
Merck Frosst, Boehringer Ingelheim
Disclosure of Commercial Support
Community Acquired Respiratory Tract Infections: The usual suspects
Statement :
This program has received no commercial financial support.
Potential for conflict(s) of interest:
Dr. Anthony Ciavarella MD has received honoraria from:
Merck Frosst, Pfizer, Bayer, and Boehringer Ingelheim.
• None of these organizations are supporting this program.
• No associated product is being discussed in this program.
Mitigating Potential Bias
Community Acquired Respiratory Tract Infections: The usual suspects
1. The content of this talk is not about products or services of any
company or group or organization with outside or commercial
interest.
2. The information presented is explicitly ‘‘evidence-based’’.
3. Sufficient time will be allowed for the audience to read and
comprehend the information being shared.
4. There will be opportunity for the audience to ask questions about
the disclosure should they arise.
Community Acquired Respiratory Tract Infections
CARTI: The Usual Suspects
Group A Strep throat
Acute Bacterial Rhino Sinusitis
Bronchitis
‘Common cold’
The ‘Flu’
Allergic Rhinitis
Acute Otitis Media
Dr. A. Ciavarella MD; Community Acquired Respiratory Tract Infections CARTI The Usual Suspects; FMF 2013 Gimli Glider Pilot School
Community Acquired Respiratory Tract Infections
CARTI: The Usual Suspect Tools
Allergic
Rhinitis1
Sneezing
Nasal
Obstruction
Nasal
Itch (pruritus)
Nasal
Rhinorrhea
+ Itchy watery
Eyes (conjunctivits)
SOIRE
ABRS2
Facial
Pain/pressure/
fullness
Nasal
Obstruction
‘Cold’ 3
‘Strep’ 5
Sore throat sneezing Fever+Cough >38°C 1. Fever >38°C
Myalgia
2. Tender ant.
Cough
Rapid Onset < 48 hrs cervical Adenopathy
Nasal
Chills or Sweating
Obstruction
3. Tonsillar swelling
Nasal Purulence/
Nasal
discoloured
Rhinorrhea
postnasal Discharge
Ill feeling
hyposmia/anosmia
Everywhere
(Smell)
PODS
‘Flu’ 4
SCORE
or exudate
4. Age 3 to 14
5. No cough
Flu Can
Make Rapid
Chills or Sweating
FAT And
No cough
1. Small P, Frnkiel S, Becker A, et al.. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. http://www.ccohs.ca/oshanswers/diseases/common_cold.html accessed 2013 October 21
4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62
5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.ht
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
CARTI: The Unusual Suspects
Mononucleosis
Acute Frontal Bacterial Rhino Sinusitis
Acute Exacerbation COPD
Pertussis
Community Acquired Pneumonia
Asthma worsening
Tuberculosis
Dr. A. Ciavarella MD; Community Acquired Respiratory Tract Infections CARTI The Usual Suspects; FMF 2013 Gimli Glider Pilot School
Community Acquired Respiratory Tract Infections
CARTI: The Unusual Suspect Tools
WCBC + S
CAP1
Cough
Fever
Pleuritic chest pain
Physical Examination
Sputum probable
CXR necessary
CURB -65
Frontal
Sinusitis2
Fever; Rapid onset
Chills & sweating
Frontal sinus pain
POSSIBLE
Systemic symptoms
Neurological symptoms
Occular symptoms
PODS
AECOPD3
Sustained Worsening
of dyspnea (SOB), Cough
or Phlegm production
leading to an increase in
the use of Maintenance
Medications and/or
supplemental with
Additional Medications
Cough
Phlegm
SOB
Worsening &
More Medicine
Asthma Worsening4
Asthma symptoms Day > 4 days / wk
Any Night time Asthma symptoms
Any interference with Usual Activities
or exercise
4. Flow < 80% of personal best
5. Reliever medication > 4 doses / wk
(including exercise)
6. Sputum Eosinophils > 3%.
7. Employment or school - any days lost
8. Exacerbation frequent within the past
year or any not mild exacerbations.
1.
2.
3.
DNA FREE E
1. RR, Lemonovich TL. Diagnosis and management of CAPin adults. Am Fam Physician. 2011 Jun 1;83(11):1299-306. PubMed PMID: 21661712
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease
– 2008 update – highlights for primary care. Can Respir J. 2008;15(Suppl A):1A-8A..
4. Lougheed MD et al; Canadian Thoracic Society 2012; Can Respir J Vol 19 No 2 March/April 2012
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
Viral URTI*: Symptom Severity vs. Time
Severity
Fever
Respiratory Symptoms
*URTI Upper Respiratory Tract Infection
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Adapted from Wald E.R. et al; Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years;
American Academy of Pediatrics; (doi: 10.1542/peds.2013-1071)
Community Acquired Respiratory Tract Infections
CARTI: The Usual Suspects
Group A Strep throat
Acute Bacterial Rhino Sinusitis
Bronchitis
‘Common cold’
The ‘Flu’
Allergic Rhinitis
Acute Otitis Media
Dr. A. Ciavarella MD; Community Acquired Respiratory Tract Infections CARTI The Usual Suspects; FMF 2013 Gimli Glider Pilot School
Community Acquired Respiratory Tract Infections
Common Cold: Symptom Pattern
• Early signs of a cold are a:
‘Common cold’
– Sore, Scratchy throat
Sore throat sneezing
– Sneezing
Cough
– Runny nose
Nasal Obstruction
• Other symptoms that may occur later include:
Nasal Rhinorrhea
ill feeling Everywhere
– Headache
– Stuffy nose (Obstruction)
– Watering eyes
– Hacking Cough
– ill-feeling Everywhere: Chills, muscle aches, and general malaise
Duration 2 to 7 days
Some Cases May Last for 2 Weeks
Canadian Centre for Occupational Health and Safety; http://www.ccohs.ca/oshanswers/diseases/common_cold.html#_1_2 accessed 2013 October
Community Acquired Respiratory Tract Infections
CARTI: ‘common cold’ symptoms
Severity
‘Common cold’
Sore throat sneezing
Cough
Nasal Obstruction
Fever
Nasal Rhinorrhea
‘cold’ symptoms
ill feeling Everywhere
Duration
2 to 7 days
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Canadian Centre for Occupational Health and Safety; http://www.ccohs.ca/oshanswers/diseases/common_cold.html#_1_2
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accessed 2013 October
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Community Acquired Respiratory Tract Infections
CARTI: ‘common cold’ SCORE
Severity
‘Common cold’
Sore throat sneezing
Cough
Nasal Obstruction
Fever
Nasal Rhinorrhea
SCORE
ill feeling Everywhere
Duration
2 to 7 days
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Canadian Centre for Occupational Health and Safety; http://www.ccohs.ca/oshanswers/diseases/common_cold.html#_1_2
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accessed 2013 October
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Community Acquired Respiratory Tract Infections
Acute Bacterial Rhino Sinusitis: Biphasic Pattern
Severity
ABRS
Facial Pain/pressure/fullness
Nasal Obstruction
Nasal Purulence/discoloured
postnasal Discharge
hyposmia/anosmia (Smell)
SCORE
worsening after
5 to 7 days with
similar symptoms
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Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Community Acquired Respiratory Tract Infections
Acute Bacterial Rhino Sinusitis: PODS
Severity
ABRS
Facial Pain/pressure/fullness
Nasal Obstruction
Nasal Purulence/discoloured
postnasal Discharge
SCORE
hyposmia/anosmia (Smell)
PODS
worsening after
5 to 7 days with
similar symptoms
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Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Community Acquired Respiratory Tract Infections
Acute Bacterial Rhino Sinusitis: Diagnosis
P
Facial
Pain/Pressure/
Fullness
O
Nasal
Obstruction
D
Nasal Purulence/
Discolored
Postnasal
Discharge
S
Hyposmia/
Anosmia
(Smell)
ABRS diagnosis requires the presence of at least 2 major PODS symptoms;
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Community Acquired Respiratory Tract Infections
Acute Bacterial Rhino Sinusitis: Diagnosis
P
Facial
Pain/Pressure/
Fullness
O
Nasal
Obstruction
D
Nasal Purulence/
Discolored
Postnasal
Discharge
S
Hyposmia/
Anosmia
(Smell)
ABRS diagnosis requires the presence of at least 2 major PODS symptoms;
1 symptom must be:
nasal Obstruction or nasal purulence/discoloured postnasal Discharge
1. Worsening after 5 to 7 days (biphasic illness) with similar symptoms
2. Symptoms persist more than 7 days without improvement
3. Presence of purulence for 3 to 4 days with high fever
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Community Acquired Respiratory Tract Infections
Acute Bacterial Rhino Sinusitis: Persistent Pattern
Severity
*ABRS
Facial Pain/pressure/fullness
Nasal Obstruction
Nasal Purulence/discoloured
postnasal Discharge
PODS
hyposmia/anosmia (Smell)
more than 7 days
without improvement
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Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Community Acquired Respiratory Tract Infections
Acute Bacterial Rhino Sinusitis: Purulence with high fever
Severity
Fever
ABRS
PODS
Facial Pain/pressure/fullness
Nasal Obstruction
Nasal Purulence/discoloured
postnasal Discharge
Presence of purulence
for 3 to 4 days
with high fever
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hyposmia/anosmia (Smell)
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Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Community Acquired Respiratory Tract Infections
CARTI: The Usual Suspects
Group A Strep throat
Acute Bacterial Rhino Sinusitis
Bronchitis
‘Common cold’
The ‘Flu’
Allergic Rhinitis
Acute Otitis Media
Dr. Anthony Ciavarella BA MA MD0Common Respiratory Tract Infections: CARTI: The Usual Suspects; FMF 20136 Gimli Glider Pilot School
Community Acquired Respiratory Tract Infections
CARTI: The Unusual Suspects
Mononucleosis
Acute Frontal Bacterial Rhino Sinusitis
Acute Exacerbation COPD
Pertussis
Community Acquired Pneumonia
Asthma worsening
Tuberculosis
Dr. A. Ciavarella MD; Community Acquired Respiratory Tract Infections CARTI The Usual Suspects; FMF 2013 Gimli Glider Pilot School
CARTI: an unusual suspect
Acute Frontal Sinusitis: Purulence with high fever
Severity
Fever
PODS
PODS:
Rapid onset with fever
Chills & sweating
Frontal sinus pain
Any of:
Acute Frontal sinusitis
Requires urgent care.
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Systemic symptoms
Neurological symptoms
Occular symptoms
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Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Canadian Centre for Occupational Health and Safety; http://www.ccohs.ca/oshanswers/diseases/common_cold.html#_1_2 accessed 2013 October
CARTI: an unusual suspect
Acute Frontal Sinusitis: Requires urgent care
Severity
Fever
PODS
PODS:
Rapid onset with fever
Chills & sweating
Frontal sinus pain
Any of:
Acute Frontal sinusitis
Requires urgent care.
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Systemic symptoms
Neurological symptoms
Occular symptoms
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Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Canadian Centre for Occupational Health and Safety; http://www.ccohs.ca/oshanswers/diseases/common_cold.html#_1_2 accessed 2013 October
Community Acquired Respiratory Tract Infections
CARTI: The Usual Suspects
Group A Strep throat
Acute Bacterial Rhino Sinusitis
Bronchitis
‘Common cold’
The ‘Flu’
Allergic Rhinitis
Acute Otitis Media
Dr. Anthony Ciavarella BA MA MD0Common Respiratory Tract Infections: CARTI: The Usual Suspects; FMF 20136 Gimli Glider Pilot School
Community Acquired Respiratory Tract Infections
Rapid Onset with Fever
Severity
Fever+Cough
Fever
Rapid
Onset
< 48 hrs
Fever
+
Cough
Myalgia
Flu Can Make Rapid Chills or Sweating
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Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
Rapid Onset with Fever: Influenza
Fever+Cough
Influenza
Fever+Cough >38°C
Severity
Myalgia
Rapid
Onset
< 48 hrs
Myalgia
Rapid Onset < 48 hrs
Chills or Sweating
Chills or Sweating
Fever
+
Cough
Myalgia
Flu Can Make Rapid Chills or Sweating
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Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
Influenza Diagnosis Tool
This Influenza Diagnosis Tool gives direction.
The clinical diagnosis of influenza by exclusion.
Fever + Cough
= 2 points
Myalgia
= 2 points
Rapid Onset < 48 hrs = 1 points
Chills or Sweats
= 1 point
High risk
4 - 6 points = 59%
Flu Can Make Rapid Chills or Sweating
Ebell M.H. et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’.
J Am Board Fam Med. January-February 2012 vol. 25 no. 1 55-62
Community Acquired Respiratory Tract Infections
Rapid Onset with Fever and No cough
Severity
Fever
No cough
Fever
Adenopathy
Tonsillar swelling
or exudate
FAT And No cough
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McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue1/0075.ht
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
Rapid Onset with Fever and No cough: Group A Strep
Fever
Group A Strep
Severity
Tender ant. cervical
Adenopathy
Fever >38°C
Tender ant. cervical
Adenopathy
Tonsillar swelling or
exudate
Age 3 to 14
No cough
Tonsillar swelling or
exudate
Age 3 to 14
No cough
Fever
Adenopathy
Tonsillar swelling
or exudate
FAT And No cough
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McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.ht
adapted by Dr. A. Ciavarella MD
CARTI: Group A Strep throat GAS Assessment
FAT And No cough
Point
Fever; temperature >38°C
1
AdenopathyTender Anterior cervical
1
Tonsillar swelling or exudate
1
Age 3–14 year
1
No cough
1
Age 15–44 year
0
Age ≥45 year
-1
McIsaac WJ et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998;158:75-83
McIsaac WJ et.al. The validity of a sore throat score in family practice; CMAJ October 3, 2000 vol. 163 no. 7
CARTI: Group A Strep throat GAS Management
F A T And No cough
Score < 1
Score = 2
Score = 3
Score > 4
Risk <6%
Risk
10–28%
Risk
38-63%
No Culture
or antibiotic
is required
Culture all.
Treat only if
culture result is
positive
Culture all.
Treat with
penicillin on
clinical grounds*
*If patient has high temperature or
is clinically unwell,
and presents early in disease course
McIsaac WJ et al.; A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998;158:75-83
McIsaac WJ et.al.;The validity of a sore throat score in family practice; CMAJ October 3, 2000 vol. 163 no. 7
Community Acquired Respiratory Tract Infections
CARTI: The Usual Suspect Tools
Allergic
Rhinitis1
Sneezing
Nasal
Obstruction
Nasal
Itch (pruritus)
Nasal
Rhinorrhea
+ Itchy watery
Eyes (conjunctivits)
SOIRE
ABRS2
Facial
Pain/pressure/
fullness
Nasal
Obstruction
‘Cold’ 3
‘Strep’ 5
Sore throat sneezing Fever+Cough >38°C 1. Fever >38°C
Myalgia
2. Tender ant.
Cough
Rapid Onset < 48 hrs cervical Adenopathy
Nasal
Chills or Sweating
Obstruction
3. Tonsillar swelling
Nasal Purulence/
Nasal
discoloured
Rhinorrhea
postnasal Discharge
Ill feeling
hyposmia/anosmia
Everywhere
(Smell)
PODS
‘Flu’ 4
SCORE
or exudate
4. Age 3 to 14
5. No cough
Flu Can
Make Rapid
Chills or Sweating
FAT And
No cough
1. Small P, Frnkiel S, Becker A, et al.. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. http://www.ccohs.ca/oshanswers/diseases/common_cold.html accessed 2013 October 21
4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62
5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.ht
adapted by Dr. A. Ciavarella MD
Allergic Rhinitis
S
O
I
R
E
Sneezing
Nasal
Obstruction
Nasal Itch
(pruritus)
Nasal
Rhinorrhea
+ Itchy Watery
Eyes
(conjunctivits)
Allergic Rhinitis Diagnosis:
2 or More of ‘S O I R E’ Symptoms
for More Than 1 Hour on Most Days
● The previous classification of seasonal or perennial Allergic Rhinitis is
being replaced with intermittent and persistent Allergic Rhinitis1
● Intermittent episode = symptoms last <6 weeks
● Persistent episode = symptoms last >6 weeks
1. Small P. et al. Rhinitis: A practical and comprehensive approach to assessment and therapy. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.
CARTI: The Usual Suspects Diagnoses
Clinical
Clinical
Clinical
Clinical
Throat Swab
Allergic
Rhinitis1
ABRS2
‘Cold’ 3
‘Flu’ 4
‘Strep’ 5
Sneezing
Nasal
Obstruction
Nasal
Itch (pruritus)
Nasal
Rhinorrhea
+ Itchy watery
Eyes (conjunctivits)
allergy
testing when
convenient
Facial
Pain/pressure/
fullness
Nasal
Obstruction
Sore throat sneezing Fever+Cough >38°C 1. Fever >38°C
Myalgia
2. Tender ant.
Cough
Rapid Onset < 48 hrs cervical Adenopathy
Nasal
Chills or Sweating
Obstruction
3. Tonsillar swelling
Nasal Purulence/
Nasal
discoloured
Rhinorrhea
postnasal Discharge
Ill feeling
hyposmia/anosmia
Everywhere
(Smell)
nasal swabs or
sinus x-rays
not necessary
no
investigations
Investigations
not necessary.
Posterior
nasophryngeal
swab optional.
or exudate
4. Age 3 to 14
5. No cough
Throat Swab
Necessary.
1. Small P, Frnkiel S, Becker A, et al.. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. http://www.ccohs.ca/oshanswers/diseases/common_cold.html accessed 2013 October 21
4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62
5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.ht
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
CARTI: The Usual Suspects
Group A Strep throat
Acute Bacterial Rhino Sinusitis
Bronchitis
‘Common cold’
The ‘Flu’
Allergic Rhinitis
Acute Otitis Media
Dr. A. Ciavarella MD; Community Acquired Respiratory Tract Infections CARTI The Usual Suspects; FMF 2013 Gimli Glider Pilot School
Community Acquired Respiratory Tract Infections
CARTI: Bronchitis symptoms
self limiting respiratory symptoms
lasting up to 3 weeks 2
Severity
Fever < 3 days
Chest discomfort
Sputum production
Wheezes might be present
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20
ROSS H. ALBERT ; Diagnosis and Treatment of Acute Bronchitis Am Fam Physician. 2010 Dec 1;82(11):1345-1350. http://www.aafp.org/afp/2010/1201/p1345.html
Little P. et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293(24):3029–3035..
Gwaltney J. Acute bronchitis. In: Mandell G, Bennett J, and Dolin R (eds.).
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 5th edition, Churchill and Livingstone, Edinburgh, 2000.
21
Community Acquired Respiratory Tract Infections
CARTI: Bronchitis
self limiting respiratory symptoms
lasting up to 3 weeks 2
Severity
Fever < 3 days
Chest discomfort
Green/yellow sputum production
is indicative of inflammation and
does not reliably differentiate between
bacterial and viral lower respiratory tract infections.2
00
1.
2.
3.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
Sputum production
Wheezes might be present
17
18
19
20
ROSS H. ALBERT ; Diagnosis and Treatment of Acute Bronchitis Am Fam Physician. 2010 Dec 1;82(11):1345-1350. http://www.aafp.org/afp/2010/1201/p1345.html
Little P. et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293(24):3029–3035..
Gwaltney J. Acute bronchitis. In: Mandell G, Bennett J, and Dolin R (eds.).
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 5th edition, Churchill and Livingstone, Edinburgh, 2000.
21
Community Acquired Respiratory Tract Infections
CARTI: Bronchitis symptoms
Severity
Antibiotics are generally not indicated for bronchitis, and
should be used only if pertussis is suspected to reduce
transmission or if the patient is at increased risk of developing
pneumonia (e.g., patients 65 years or older*).
Fever < 3 days
Chest discomfort
Green/yellow sputum production
is indicative of inflammation and
does not reliably differentiate between
bacterial and viral lower respiratory tract infections.2
00
1.
2.
3.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
Sputum production
Wheezes might be present
17
18
19
20
ROSS H. ALBERT ; Diagnosis and Treatment of Acute Bronchitis Am Fam Physician. 2010 Dec 1;82(11):1345-1350. http://www.aafp.org/afp/2010/1201/p1345.html
Little P. et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293(24):3029–3035..
Gwaltney J. Acute bronchitis. In: Mandell G, Bennett J, and Dolin R (eds.).
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 5th edition, Churchill and Livingstone, Edinburgh, 2000.
21
Community Acquired Respiratory Tract Infections
CARTI: Bronchitis symptoms
Severity
Antibiotics are generally not indicated for bronchitis, and
should be used only if pertussis is suspected to reduce
transmission or if the patient is at increased risk of developing
pneumonia (e.g., patients 65 years or older*).
*NNT is 39 in patients 65 years or older 1 .
Fever < 3 days
Chest discomfort
Green/yellow sputum production
is indicative of inflammation and
does not reliably differentiate between
bacterial and viral lower respiratory tract infections.2
00
1.
2.
3.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
Sputum production
Wheezes might be present
17
18
19
20
ROSS H. ALBERT ; Diagnosis and Treatment of Acute Bronchitis Am Fam Physician. 2010 Dec 1;82(11):1345-1350. http://www.aafp.org/afp/2010/1201/p1345.html
Little P. et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293(24):3029–3035..
Gwaltney J. Acute bronchitis. In: Mandell G, Bennett J, and Dolin R (eds.).
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 5th edition, Churchill and Livingstone, Edinburgh, 2000.
21
Community Acquired Respiratory Tract Infections
CARTI: The Unusual Suspect Tools
CAP1
Cough
Fever
Pleuritic chest pain
Physical Examination
Sputum probable
CXR necessary
CURB -65
1. RR, Lemonovich TL. Diagnosis and management of CAPin adults. Am Fam Physician. 2011 Jun 1;83(11):1299-306. PubMed PMID: 21661712
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease
– 2008 update – highlights for primary care. Can Respir J. 2008;15(Suppl A):1A-8A..
4. Lougheed MD et al; Canadian Thoracic Society 2012; Can Respir J Vol 19 No 2 March/April 2012
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
CARTI: Bronchitis symptoms
Severity
Antibiotics are generally not indicated for bronchitis, and
should be used only if pertussis is suspected to reduce
transmission or if the patient is at increased risk of developing
pneumonia (e.g., patients 65 years or older*).
*NNT is 39 in patients 65 years or older 1 .
Fever < 3 days
Chest discomfort
Sputum production
Wheezes might be present
Green/yellow sputum production:
is indicative of inflammation and
does not reliably differentiate between
bacterial and viral lower respiratory tract infections.2
00
1.
2.
3.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
ROSS H. ALBERT ; Diagnosis and Treatment of Acute Bronchitis Am Fam Physician. 2010 Dec 1;82(11):1345-1350. http://www.aafp.org/afp/2010/1201/p1345.html
Little P. et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293(24):3029–3035..
Gwaltney J. Acute bronchitis. In: Mandell G, Bennett J, and Dolin R (eds.).
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 5th edition, Churchill and Livingstone, Edinburgh, 2000.
21
CARTI: Unusual Suspects
Pertussis Typical Clinical Phases*
Paroxysmal
Cough
Cough Paroxysmal
Cough Whooping
Vomiting
Cyanosis
Apnea
Catarrhal:
Mild cough
Runny nose
Mild fever
Apnea in infants
Convalescent:
Cough
less paroxysmal
disappears
in weeks
*The illness can be milder and the typical "whoop" absent in children, teens, and adults who have been
vaccinated with a pertussis vaccine.
Incubation
7-10 days
Catarrhal
00
01
Paroxysmal
02
03
04
05
Convalescent
06
07
Tozzi A.E.; Diagnosis and management of pertussis; CMAJ 2005;172(4):509-15
08
weeks to months
Community Acquired Respiratory Tract Infections
CARTI: Bronchitis
self limiting respiratory symptoms
lasting up to 3 weeks 2
Severity
Fever < 3 days
Chest discomfort
Sputum production
Wheezes might be present
Green/yellow sputum production:
is indicative of inflammation and
does not reliably differentiate between
bacterial and viral lower respiratory tract infections.2
00
1.
2.
3.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
ROSS H. ALBERT ; Diagnosis and Treatment of Acute Bronchitis Am Fam Physician. 2010 Dec 1;82(11):1345-1350. http://www.aafp.org/afp/2010/1201/p1345.html
Little P. et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293(24):3029–3035..
Gwaltney J. Acute bronchitis. In: Mandell G, Bennett J, and Dolin R (eds.).
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 5th edition, Churchill and Livingstone, Edinburgh, 2000.
21
Community Acquired Respiratory Tract Infections
CARTI: Unusual Suspect AECOPD
AECOPD3
Sustained Worsening
of dyspnea (SOB), Cough
or Phlegm production
leading to an increase in
the use of Maintenance
Medications and/or
supplemental with
Additional Medications
Cough
Phlegm
SOB
Worsening &
More Medicine
1. RR, Lemonovich TL. Diagnosis and management of CAPin adults. Am Fam Physician. 2011 Jun 1;83(11):1299-306. PubMed PMID: 21661712
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease
– 2008 update – highlights for primary care. Can Respir J. 2008;15(Suppl A):1A-8A..
4. Lougheed MD et al; Canadian Thoracic Society 2012; Can Respir J Vol 19 No 2 March/April 2012
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
CARTI: Bronchitis
self limiting respiratory symptoms
lasting up to 3 weeks 2
Severity
Fever < 3 days
Chest discomfort
Sputum production
Wheezes might be present
Green/yellow sputum production:
is indicative of inflammation and
does not reliably differentiate between
bacterial and viral lower respiratory tract infections.2
00
1.
2.
3.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
ROSS H. ALBERT ; Diagnosis and Treatment of Acute Bronchitis Am Fam Physician. 2010 Dec 1;82(11):1345-1350. http://www.aafp.org/afp/2010/1201/p1345.html
Little P. et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293(24):3029–3035..
Gwaltney J. Acute bronchitis. In: Mandell G, Bennett J, and Dolin R (eds.).
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 5th edition, Churchill and Livingstone, Edinburgh, 2000.
21
Community Acquired Respiratory Tract Infections
CARTI: Unusual Suspect Asthma Worsening
WCBC + S
Asthma Worsening4
Asthma symptoms Day > 4 days / wk
Any Night time Asthma symptoms
Any interference with Usual Activities
or exercise
4. Flow < 80% of personal best
5. Reliever medication > 4 doses / wk
(including exercise)
6. Sputum Eosinophils > 3%.
7. Employment or school - any days lost
8. Exacerbation frequent within the past
year or any not mild exacerbations.
1.
2.
3.
DNA FREE E
1. RR, Lemonovich TL. Diagnosis and management of CAPin adults. Am Fam Physician. 2011 Jun 1;83(11):1299-306. PubMed PMID: 21661712
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease
– 2008 update – highlights for primary care. Can Respir J. 2008;15(Suppl A):1A-8A..
4. Lougheed MD et al; Canadian Thoracic Society 2012; Can Respir J Vol 19 No 2 March/April 2012
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
CARTI: Unusual Suspect Tools
WCBC + S
CAP1
Cough
Fever
Pleuritic chest pain
Physical Examination
Sputum probable
CXR necessary
CURB -65
Frontal
Sinusitis2
Fever; Rapid onset
Chills & sweating
Frontal sinus pain
POSSIBLE
Systemic symptoms
Neurological symptoms
Occular symptoms
PODS
AECOPD3
Sustained Worsening
of dyspnea (SOB), Cough
or Phlegm production
leading to an increase in
the use of Maintenance
Medications and/or
supplemental with
Additional Medications
Cough
Phlegm
SOB
Worsening &
More Medicine
Asthma Worsening4
Asthma symptoms Day > 4 days / wk
Any Night time Asthma symptoms
Any interference with Usual Activities
or exercise
4. Flow < 80% of personal best
5. Reliever medication > 4 doses / wk
(including exercise)
6. Sputum Eosinophils > 3%.
7. Employment or school - any days lost
8. Exacerbation frequent within the past
year or any not mild exacerbations.
1.
2.
3.
DNA FREE E
1. RR, Lemonovich TL. Diagnosis and management of CAPin adults. Am Fam Physician. 2011 Jun 1;83(11):1299-306. PubMed PMID: 21661712
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease
– 2008 update – highlights for primary care. Can Respir J. 2008;15(Suppl A):1A-8A..
4. Lougheed MD et al; Canadian Thoracic Society 2012; Can Respir J Vol 19 No 2 March/April 2012
adapted by Dr. A. Ciavarella MD
CARTI: The Usual Suspects ?Antibiotics?
NO
NO
Allergic
Rhinitis1
Sneezing
Nasal
Obstruction
Nasal
Itch (pruritus)
Nasal
Rhinorrhea
+ Itchy watery
Eyes (conjunctivits)
ABRS2
Facial
Pain/pressure/
fullness
Nasal
Obstruction
‘Cold’ 3
NO
‘Flu’ 4
YES
‘Strep’ 5
Sore throat sneezing Fever+Cough >38°C 1. Fever >38°C
Myalgia
2. Tender ant.
Cough
Rapid Onset < 48 hrs cervical Adenopathy
Nasal
Chills or Sweating
Obstruction
3. Tonsillar swelling
Nasal Purulence/
Nasal
discoloured
Rhinorrhea
postnasal Discharge
Ill feeling
hyposmia/anosmia
Everywhere
(Smell)
or exudate
4. Age 3 to 14
5. No cough
Culture all.
Treat with
penicillin on
clinical grounds*
1. Small P, Frnkiel S, Becker A, et al.. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. http://www.ccohs.ca/oshanswers/diseases/common_cold.html accessed 2013 October 21
4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62
5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.ht
adapted by Dr. A. Ciavarella MD
CARTI: Group A Strep throat GAS Management
F A T And No cough
Score < 1
Score = 2
Score = 3
Score > 4
Risk <6%
Risk
10–28%
Risk
38-63%
No Culture
or antibiotic
is required
Culture all.
Treat only if
culture result is
positive
Culture all.
Treat with
penicillin on
clinical grounds*
*If patient has high temperature or
is clinically unwell,
and presents early in disease course
McIsaac WJ et al.; A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998;158:75-83
McIsaac WJ et.al.;The validity of a sore throat score in family practice; CMAJ October 3, 2000 vol. 163 no. 7
CARTI: The Usual Suspects ?Antibiotics?
Maybe
Allergic
Rhinitis1
Sneezing
Nasal
Obstruction
Nasal
Itch (pruritus)
Nasal
Rhinorrhea
+ Itchy watery
Eyes (conjunctivits)
ABRS2
Facial
Pain/pressure/
fullness
Nasal
Obstruction
‘Cold’ 3
‘Flu’ 4
‘Strep’ 5
Sore throat sneezing Fever+Cough >38°C 1. Fever >38°C
Myalgia
2. Tender ant.
Cough
Rapid Onset < 48 hrs cervical Adenopathy
Nasal
Chills or Sweating
Obstruction
3. Tonsillar swelling
Nasal Purulence/
Nasal
discoloured
Rhinorrhea
postnasal Discharge
Ill feeling
hyposmia/anosmia
Everywhere
(Smell)
or exudate
4. Age 3 to 14
5. No cough
1. Small P, Frnkiel S, Becker A, et al.. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. http://www.ccohs.ca/oshanswers/diseases/common_cold.html accessed 2013 October 21
4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62
5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.ht
adapted by Dr. A. Ciavarella MD
CARTI Treatment:
ABRS Purulence with high fever
Severity
Antibiotics Yes
Fever
PODS
Presence of purulence
for 3 to 4 days
with high fever
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
CARTI Treatment:
ABRS: Persistent or Biphasic illness
Severity
Antibiotics maybe
Persistent
Biphasic illness
PODS
SCORE
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Algorithm for the Diagnosis & Treatment of ABRS
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
ABRS: Mild, Moderate or Severe
None
Major Symptoms
P
Facial Pain/
Pressure/Fullness
O
Nasal Obstruction
D
Nasal Purulence/Discolored
Postnasal Discharge
S
Hyposmia/Anosmia (Smell)
Mild
Moderate
Severe
Occasional
Limited Episode
Steady
Symptoms but
Easily Tolerated
Hard to Tolerate &
May Interfere with
Activity or Sleep
ABRS diagnosis requires the presence of at least 2 major PODS symptoms;
1 symptom must be nasal Obstruction or nasal purulence/discoloured postnasal Discharge
Consider ABRS
Under Any One of the
Following Conditions
1) Worsening after 5 to 7 days (biphasic illness) with similar symptoms
2) Symptoms persist more than 7 days without improvement
3) Presence of purulence for 3 to 4 days with high fever
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
ABRS: Case 1
• Previously healthy 32-year-old
non-smoking mother
• Recent onset of symptoms of an
upper respiratory tract infection (URTI)
– Persistent nasal obstruction
– Right-sided maxillary facial pain
– Yellowish secretions
• Have lasted 9 days from the outset but
has not limited work / family activities
• Have not responded to OTC medication
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
ABRS: Case 1
• Previously healthy 32-year-old
non-smoking mother
• Recent onset of symptoms of an
upper respiratory tract infection (URTI)
– Persistent nasal obstruction
– Right-sided maxillary facial pain
– Yellowish secretions
• Have lasted 9 days from the outset but
has not limited work / family activities
• Have not responded to OTC medication
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
ABRS: Mild, Moderate
None
Major Symptoms
P
Facial Pain/
Pressure/Fullness
O
Nasal Obstruction
D
Nasal Purulence/Discolored
Postnasal Discharge
S
Hyposmia/Anosmia (Smell)
Mild
Moderate
Severe
Occasional
Limited Episode
Steady
Symptoms but
Easily Tolerated
Hard to Tolerate &
May Interfere with
Activity or Sleep
ABRS diagnosis requires the presence of at least 2 major PODS symptoms;
1 symptom must be nasal Obstruction or nasal purulence/discoloured postnasal Discharge
Consider ABRS
Under Any One of the
Following Conditions
1) Worsening after 5 to 7 days (biphasic illness) with similar symptoms
2) Symptoms persist more than 7 days without improvement
3) Presence of purulence for 3 to 4 days with high fever
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Algorithm for the Diagnosis & Treatment of ABRS
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
CARTI: ABRS Treatment
INCS vs antibiotics
Mean change from baseline
(days 2-15)
Baseline
scores:
8.36
8.53
8.17
Placebo
(n=247)
Amoxicillin 0.5 g TID
(n=249)
MFNS 200 µg OD
(n=240)
8.28
MFNS 200 µg BID
(n=234)
-3.6
-3.8
-3.75
-4.0
-4.01
-4.13
-4.2
-4.4
-4.51
-4.6
*P<0.05 vs. Placebo
P=0.057 vs. Amoxicillin
*†
Change in mean AM/PM major symptom score from
baseline over treatment period (days 2-15)
Meltzer et al. J Allergy Clin Immunol. 2005;116:1289.
Algorithm for the Diagnosis & Treatment of ABRS
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
ABRS: Case 2
• Previously healthy 32-year-old
non-smoking mother
• Recent onset of symptoms of an
upper respiratory tract infection
(URTI)
–
–
–
–
Persistent nasal obstruction
Right-sided maxillary facial pain
Yellowish secretions
now interfering with sleep
• Have lasted 2 weeks from the
outset and has not responded to
INCS medication
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg
ABRS: Case 2
• Previously healthy 32-year-old
non-smoking mother
• Recent onset of symptoms of an
upper respiratory tract infection
(URTI)
–
–
–
–
Persistent nasal obstruction
Right-sided maxillary facial pain
Yellowish secretions
now interfering with sleep
• Have lasted 2 weeks from the
outset and has not responded to
INCS medication
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg
ABRS: Severe
None
Major Symptoms
P
Facial Pain/
Pressure/Fullness
O
Nasal Obstruction
D
Nasal Purulence/Discolored
Postnasal Discharge
S
Hyposmia/Anosmia (Smell)
Mild
Moderate
Severe
Occasional
Limited Episode
Steady
Symptoms but
Easily Tolerated
Hard to Tolerate &
May Interfere with
Activity or Sleep
ABRS diagnosis requires the presence of at least 2 major PODS symptoms;
1 symptom must be nasal Obstruction or nasal purulence/discoloured postnasal Discharge
Consider ABRS
Under Any One of the
Following Conditions
1) Worsening after 5 to 7 days (biphasic illness) with similar symptoms
2) Symptoms persist more than 7 days without improvement
3) Presence of purulence for 3 to 4 days with high fever
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Algorithm for the Diagnosis & Treatment of ABRS
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
First-line Therapy
• In severe ABRS
• In Moderate ABRS if INCS are not
efficacious
• Antibiotics recommended:
– Amoxicillin 500 mg TID
– Macrolide for penicillin-allergic
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A,
Bouchard J, Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011
Algorithm for the Diagnosis & Treatment of ABRS
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A, Bouchard J,
Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011 April;40(2):S91
Second-line Therapy
• Risk factors for immunosuppression
• Symptoms suggesting frontal or sphenoid sinusitis
• Presence of risk factors for antibiotic resistance
– Previous antibiotic ≤3 months
– Day care exposure
– Failure of first-line antibiotic
• Initial therapy with a second-line antibiotic
– Amoxicillin/clavulanic acid 875 mg BID x 10–14d
– Moxifloxacin 400 mg QD x 10–14d
Canadian clinical practice guidelines for acute and chronic rhinosinusitis; Desrosiers M, Evans G, Keith P, Wright E, Kaplan A,
Bouchard J, Ciavarella A et al. ; Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2., And J Otolaryngol Head Neck Surg. 2011
Community Acquired Respiratory Tract Infections
CARTI: The Usual Suspects
Group A Strep throat
Acute Bacterial Rhino Sinusitis
Bronchitis
‘Common cold’
The ‘Flu’
Allergic Rhinitis
Acute Otitis Media
Dr. A. Ciavarella MD; Community Acquired Respiratory Tract Infections CARTI The Usual Suspects; FMF 2013 Gimli Glider Pilot School
Community Acquired Respiratory Tract Infections
CARTI: The Unusual Suspects
Mononucleosis
Acute Frontal Bacterial Rhino Sinusitis
Acute Exacerbation COPD
Pertussis
Community Acquired Pneumonia
Asthma worsening
Tuberculosis
Dr. A. Ciavarella MD; Community Acquired Respiratory Tract Infections CARTI The Usual Suspects; FMF 2013 Gimli Glider Pilot School
Community Acquired Respiratory Tract Infections
CARTI: Usual Suspect Tools
Allergic
Rhinitis1
Sneezing
Nasal
Obstruction
Nasal
Itch (pruritus)
Nasal
Rhinorrhea
+ Itchy watery
Eyes (conjunctivits)
SOIRE
ABRS2
Facial
Pain/pressure/
fullness
Nasal
Obstruction
‘Cold’ 3
‘Strep’ 5
Sore throat sneezing Fever+Cough >38°C 1. Fever >38°C
Myalgia
2. Tender ant.
Cough
Rapid Onset < 48 hrs cervical Adenopathy
Nasal
Chills or Sweating
Obstruction
3. Tonsillar swelling
Nasal Purulence/
Nasal
discoloured
Rhinorrhea
postnasal Discharge
Ill feeling
hyposmia/anosmia
Everywhere
(Smell)
PODS
‘Flu’ 4
SCORE
or exudate
4. Age 3 to 14
5. No cough
Flu Can
Make Rapid
Chills or Sweating
FAT And
No cough
1. Small P, Frnkiel S, Becker A, et al.. Journal of Otolaryngology. 2007;36(Supl 1):S5-S27.
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. http://www.ccohs.ca/oshanswers/diseases/common_cold.html accessed 2013 October 21
4. Ebell et al. ‘Development and Validation of a Clinical Decision Rule for the Diagnosis of Influenza’. JABFM Jan-Feb 2012 vol. 25 no. 1 55-62
5. McIsaac WJ et.al.CMAJ 1998;158:75-83. Available: www.cma.ca/cmaj/vol-158/issue-1/0075.ht
adapted by Dr. A. Ciavarella MD
Community Acquired Respiratory Tract Infections
CARTI: Unusual Suspect Tools
WCBC + S
CAP1
Cough
Fever
Pleuritic chest pain
Physical Examination
Sputum probable
CXR necessary
CURB -65
Frontal
Sinusitis2
Fever; Rapid onset
Chills & sweating
Frontal sinus pain
POSSIBLE
Systemic symptoms
Neurological symptoms
Occular symptoms
PODS
AECOPD3
Sustained Worsening
of dyspnea (SOB), Cough
or Phlegm production
leading to an increase in
the use of Maintenance
Medications and/or
supplemental with
Additional Medications
Cough
Phlegm
SOB
Worsening &
More Medicine
Asthma Worsening4
Asthma symptoms Day > 4 days / wk
Any Night time Asthma symptoms
Any interference with Usual Activities
or exercise
4. Flow < 80% of personal best
5. Reliever medication > 4 doses / wk
(including exercise)
6. Sputum Eosinophils > 3%.
7. Employment or school - any days lost
8. Exacerbation frequent within the past
year or any not mild exacerbations.
1.
2.
3.
DNA FREE E
1. RR, Lemonovich TL. Diagnosis and management of CAPin adults. Am Fam Physician. 2011 Jun 1;83(11):1299-306. PubMed PMID: 21661712
2. Desrosiers et al.; Allergy, Asthma & Clinical Immunology 2011, 7:2 doi:10.1186/1710-1492-7-2;
3. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease
– 2008 update – highlights for primary care. Can Respir J. 2008;15(Suppl A):1A-8A..
4. Lougheed MD et al; Canadian Thoracic Society 2012; Can Respir J Vol 19 No 2 March/April 2012
adapted by Dr. A. Ciavarella MD
CARTI: Suspects
Usual
Acute Bacterial Rhino Sinusitis
Influenza
Group A Strep throat
‘Common cold’
Bronchitis
&
Unusual
Acute frontal Bacterial Rhino Sinusitis
Community Acquired Pneumonia
Mononucleosis
Pertussis
Asthma worsening
Acute Exacerbation COPD
Allergic Rhinitis
Tuberculosis
Acute Otitis Media
Dr. A. Ciavarella MD; Community Acquired Respiratory Tract Infections CARTI The Usual Suspects; FMF 2013 Gimli Glider Pilot School
Family Medicine Forum
College of Family Physicians of Canada
Common Respiratory Tract Infections
CARTI: The usual suspects
Dr. Anthony Ciavarella BA MA MD MCFP
FMF 2013 Vancouver BC