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u N f l t s r v U n y g a C d o e c i L I.

INTRODUCTION Upper respiratory tract infection (URI) is a nonspecific term used t o describe acute infections involving the nose, paranasal sinuses, pharynx, larynx,trachea, and bronchi. The prototype is the illness known as the common cold,w h i c h w i l l b e d i s c u s s e d h e r e , i n a d d i t i o n t o p h a r y n g i t i s , s i n u s i t i s , a n d tracheobronchitis. Influenza is a systemic illness t h a t i n v o l v e s t h e u p p e r respiratory tract and should be differentiated from other URIs.V i r u s e s c a u s e m o s t U R I s , w i t h r h i n o v i r u s , p a r a i n f l u e n z a v i r u s , coronavirus, adenovirus, respiratory syncytial virus, coxsackievirus, and influenzavirus accounting for most cases. Human metapneumovirus is a newly discoveredagent causing URIs. Group A beta-hemolytic streptococci (GABHS) cause 5% to1 0 % o f c a s e s o f p h a r yn g i t i s i n a d u l t s . Other less common causes of bacterial p h a r y n g i t i s i n c l u d e g r o u p C b e t a h e m o l yt i c s t r e p t o c o c c i , Corynebacteriumdiphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydia p n e u m o n i a e , M y c o p l a s m a p n e u m o n i a e , a n d h e r p e s s i m p l e x v i r u s . Streptococcus pneumoniae, Haemophilus influenzae , and Moraxella catarrhalis are the most common organisms that cause the bacterial superinfection of viral acute sinusitis. Less than 10% of cases of acute tracheobronchitis are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae , or C. pneumoniae . Most URIs occurs more frequently during the cold winter months, becauseo f o v e r c r o w d i n g . A d u l t s d e v e l o p a n a v e r a g e o f t w o t o f o u r c olds annually.Antigenic variation of hundreds of respiratory virus e s r e s u l t s i n r e p e a t e d c i r c u l a t i o n i n t h e c o m m u n i t y. A c o r yz a s yn d r o m e i s b y f a r t h e m o s t c o m m o n cause of physician visits in the United States. Acute pharyngitis accounts for 1%to 2% of all visits to outpatient and emergency departments, resulting in 7 millionannual visits by adults alone. Acute bacterial sinusitis develops in 0.5% to 2% of c a s e s o f v i r a l U R I s .

A p p r o x i m a t e l y 2 0 m i l l i o n c a s e s o f a c u t e s i n u s i t i s o c c u r annually in the United States. About 12 million individuals are diagnosed with acute tracheobronchitis annually, accounting for one third of patients presenting with acute cough. The estimated economic impact of noninfluenza-related URIsis $40 billion annually. Influenza epidemics occur every year between November and March int h e N o r t h e r n H e m i s p h e r e . A p p r o x i m a t e l y t w o t h i r d s o f t h o s e i n f e c t e d w i t h influenza virus exhibit clinical illness, 25 million seek health c a r e , 1 0 0 , 0 0 0 t o 200,000 require hospitalization, and 40,000 to 60,000 die each year as a result of related complications. T h e a v e r a g e c o s t o f e a c h i n f l u e n z a e p i d e m i c i s $ 1 2 million, including the direct cost of medical care and indirect cost resulting fromlost work days. Pandemics in the 20th century claimed the lives of more than 21million people. A widespread H5N1 pandemic in birds is ongoing, with threats of a human pandemic. It is projected that such a pandemic would cost the United States $70 to $160 billion. B. OBJECTIVES OF THE STUDY This individual case study provides goals or objectives which can be used as aninstrument in assessing the patients health status and in his present conditions:1. Use to obtain a complete heath data and can be used in follow up care.2. Impart knowledge by conducting health teaching about the necessaryinformation pertaining in the disease condition.3. Understands the course and essence of the chosen care study. C. SCOPE AND LIMITATION OF THE STUDYT h e s t u d y i n c l u d e s a l l t h e d a t a g a t h e r e d d u r i n g t h e i n t e r v i e w a n d t h e observation claimed by the patient as well as the significant others. It also dealsw i t h t h e s e v e r a l f a c t o r s o b s e r v e d a n d g a t h e r e d d u r i n g t h e i n t e r v i e w . T h a t information gathered was the exact answer and the problems of the people in thecommunity and not just basing in the opinions of the students conducting theinterview of the students.The limitation of this study is limited in the place of interaction itself whichis in the hospital. This study was completed in 2 days by the interaction of thestudent and the patient.

Case Study PH2: Symptomatic management of URTIs June 2000 2 Scenario Mr Frankston is a 29 year old clerical worker who presents to his GP with symptoms of rhinosinusitis, acute sore throat and cough. He complains of headache, purulent nasal discharge, a raging sore throat and a dry cough, and general malaise lasting for 3 days. His wedding is in 3 days and his friends have urged him to see the doctor for an antibiotic so that he will be well for the wedding. His sore throat and bronchitis is highly likely to be viral and the evidence shows that he would have no benefit from antibiotic therapy in terms of duration or relief of symptoms. His GP decides an antibiotic is not required and recommends symptomatic management for his illness. and recommends symptomatic management for his illness. Inside Results Page 3

Expert Commentary Professor Chris Del Mar Page 7 Professor Andrew Gilbert Page 9 References 3 Results *** DEBBIE: NUMBER OF PEOPLE PARTICIPATING Page 12

*** JUDE: SUMMARY OF RESULTS Question 1 What non-pharmacological therapy would you recommend? Recommendation Percentage of responses pharmacists Percentage of responses GPs Rest 96 79 Fluids 79 60 Steam inhalation 54 49 Nutritional food 11 10 Warm, salty gargle 11 14 Keep warm 14 11 Avoid stress 19 6 Stop alcohol 19 6 Stop smoking 11 6 Other 0 10 Disagree, give an antibiotic 0 3 Reassurance 11 6 Warm drinks 19 3 Saline inhalation 17 3 There was a great response to this question, illustrating how many possibilities of treatment are available to the patient other than pharmacological. These ranged from the most popular of rest, increased fluid intake and inhaling steam to the simple task

of providing reassurance to support your patient. Question 2 What drug therapy would you recommend? Recommendation Specifically Percentage of responses pharmacists Percentage of responses GPs Aspirin/ paracetamol/ ibuprofen/ codeine Analgesia 100 65 Aspirin gargle 25 13 Beta-2 agonist inhaler 11 18 Theophylline preparation 11 7 Bronchodilator Only if bronchospasm 7 7 Decongestant/ Sympathomimetic - Pseudoephedrine/ phenylephrine 57 32 oral Combination cold and flu preparation, including cough mixtures 32 30 If oral contraindicated 4 0 Decongestant nasal spray 46 31 Decongestant/ Sympathomimetic -

topical Vicks vaporub/ inhaler 7 10 Anti-inflammmatory gargle/ throat spray 01 Saline nasal spray 21 6 Corticosteroid nasal spray 4 7 Betadine gargle 14 10 Lozenges anti-inflammatory, anaesthetic, anti-tussive 71 19 Cough suppressant 54 18 Decongestant/Sympathomimetic other Antibiotic 0 1 Complementary therapies Vitamin C 29 31 Garlic 11 11 4 Zinc 19 11 Echinacea 21 10 Vitamin B 7 1 Horseradish 7 4 Vitamin A 4 0 Again we see a vast range of choices available to the patient in managing his

symptoms. 100% of pharmacists responding to this question recommended either aspirin,paracetamol or ibuprofen, whilst 65% of GPs recommended the same treatment. An oral decongestant was suggested by 57% of pharmacists and 32% of GPs and 18% of GPs and 11% of pharmacists recommended a beta-2 agonist inhaler. Question 3 What counselling would you provide regarding use of drug therapy? Recommendation Drug Side effect Precaution/ Action Percentage of responses pharmacists Percentage of responses - GPs General counselling to explain drug use 93 31 Explain side effects/ contraindications 19 17 Decongestant nasal spray

Rebound congestion Short term use only 32 14 Decongestant Cough mixture Insomnia Dont use at night 32 6 Pseudephedrine Increased BP Ask if it has been taken previously and is the patient on other medication? 25 6 Codeine Constipation Maintain fluids 7 1 Aspirin Wheeze/ nausea Cease taking it 4 3 Beta-2 agonist Tremor/ tachycardia/ palpitations Cease taking it 0 3 Anti-histamine Somnolence May help to sleep at night/ dont drive 06 Alcohol Interaction with

cold/ flu preparation somnolence 0 1 Theophylline preparations May cause nausea,vomiting Cease taking it 0 1 Prevents night cough to allow better sleep 74 Specific side effects Cough suppressant If chesty cough develops, stop taking it 10 Use symptomatic therapy as required, short term only 79 46 Rest is as important

as symptomatic therapy

0 4 Does patient have any concerns?

0 1 Does patient have any allergies?

0 3 Relenza may be worth trying if its influenza

0 3 Antibiotics may help 0 3 5 Pharmacists and GPs gave a thorough account of counseling they would offer regarding the use of drug therapy. Of great importance to pharmacists was the general explanation of how to take the medication (93%) whilst 31% of GPs suggested the same. There seemed to be an across the board consensus on using the symptomatic medication exactly as indicated and only for short term; 79% of pharmacists and 46%

of GPs. GPs explored the question further with more suggestions, including one of antibiotic therapy. Question 4 What information would you provide regarding the illness? Information provided Specifically Percentage of responses pharmacists Percentage of responses GPs Reassure patient that the illness is self-limiting 61 54 Rest is paramount and will shorten the illness 39 14 Antibiotics are of no benefit in viral illness 39 32 Symptomatic treatment is for relief only and does not cure or reduce the duration of the illness 39 15 The nature of viral illnesses and

their management 21 33 Explain that the illness is infectious and describe measures to prevent infecting others 15 25 Recover in 3 days 11 11 Recover in less than 1 week 7 11 Explain duration of illness Recover in 7-10 days 7 6 If condition worsens (eg. fever) see GP 7 35 Ask the patient to provide information on their illness 43 Other 4 3 Virus may leave a long lasting viral cough 41 Question 5 What information would you provide regarding antibiotic therapy? Information provided Percentage of responses pharmacists

Percentage of responses - GPs Antibiotics are of no benefit for a viral illness and will not shorten duration or lessen illness 86 72 If condition worsens, antibiotics may be needed (fever, coloured phlegm, cough worsens ie. Signs of secondary bacterial infection) 82 38 Antibiotics may cause adverse effects (thrush/ diarrhoea/ allergy) 85 35 Antibiotics should be used only when required due to long term consequences ie. resistance 43 26 Consider the cost of the antibiotic 4 7 Return for reassessment in 48 hours 0 1 Explain time for antibiotic to work/ action/ efficacy/ side effects 01 Not using antibiotics helps to build the immune system 14 7 Assurance that antibiotic would be prescribed if

indicated 01 Continue symptomatic treatment even if starting antibiotic therapy 01 6 Send him with a script on his honeymoon in case signs of secondary infection develop 01 Emphasise that Pharmacist is in agreement with GP 7 0 Secondary bacterial infection requiring antibiotics is rare 03 Antibiotics may help 0 3 If antibiotics commenced, explain importance of finishing the course 70 Try Penicillin V first 0 1 Try Ceclor 0 1 Dont use antibiotics as a preventative measure 0 3 There appeared to be a degree of overlap in the response to these last two questions and therefore the comment on them is joint. A great degree of support to the patient is the emphasis being conveyed by respondents. Support that the illness will pass soon, support that a feeling of recovery

will soon become apparent, support that these illnesses rarely are bad or complicate and most of all support that the GP is there and to be contacted in event that the illness should worsen. Significant issues were raised in considering the antibiotic treatment of a patient including resistance, adverse effects and cost. A highly rated response of no antibiotics required for viral illnesses was balanced well with informing the patient on signs and symptoms of a secondary bacterial infection and/or wosening condition as a basis upon which to refer themselves back to the GP. 7 Expert commentary Professor Chris Del Mar Director, Centre for General Practice, University of Queensland The case describes a man with a sore throat with severe symptoms, and the complicating social factor of his impending marriage. The case description comments that: His sore throat and bronchitis is highly likely to be viral and the evidence shows that he would have no benefit from antibiotics. Actually this statement somewhat oversimplifies the condition. The best evidence comes from a Cochrane Review. 1 Even confining the discussion to the symptoms of sore throat, it suggests that antibiotics do indeed have a significant benefit. However the benefit is small, and in many cases will not justify the antibiotics. There are costs to the individual (the cost of the drug, and the risk of side effects and complications such as rashes, gastrointestinal side effects, thrush and, rarely, even serious problems

such as anaphylaxis) and to society (any subsidy to the drug costs, and the accelerated evolution of antibiotic resistant organisms in the community). Thus we have to make our decision on the basis of balancing costs and benefits. This might be so finely balanced that factors such as psychosocial ones assume greater importance than is usual in illness management. Thus I have some sympathy with the doctors (3%) who had the courage in the light of a clearly begged question to say they would prescribe antibiotics anyway.

We know that in managing sore throat, doctors take psychosocial factors very seriously, 2 and this patient has some potentially serious concerns with his impending wedding. What non-pharmacological therapy would you recommend? A majority of doctors and pharmacists recommended rest and fluids, and about half recommended steam inhalation. Only the last has been evaluated well in the literature, and the results are equivocal. A spattering of other suggestions range from gargles to avoiding smoking (whether as a direct treatment for the sore throat or as a general preventive measure, for which there is of course good evidence of general benefit, is not clear). What is missing from this list? Some recent evidence suggests that caffeine is helpful in sore throat, 3 something that many have found anecdotally in the form of a good

strong cup of coffee or tea for their sore throat! What drug therapy would you recommend? Symptomatic treatment is recommended by 80% pharmacists and nearly 50% GPs. 8 Here analgesic antipyretics such as aspirin and paracetamol are recommended by the majority 100% of the pharmacists and more GPs. There are well-conducted random controlled trials to support this, particularly non-steroidal anti-inflammatory drugs. 3 It is interesting that so many (about a third of GPs and pharmacists) recommend that vitamin C should be used. The evidence is equivocal. There is however better evidence for zinc, with between 10-20% of GPs and pharmacists recommending this, and the same sort of response for Echinacea, for which the evidence is very weak. What counselling would you provide regarding use of drug therapy? Most pharmacists and GPs reassure patients about the self-limiting nature of sore throat. Both GPs and pharmacists are more inclined to use explanations that emphasise the patho-physiological model of the illness (which organisms are likely, for example, and their susceptibility to antibiotics). I wonder about the evidence for the statement volunteered by 14% pharmacists and 7% GPs that Not using antibiotics builds the immune system. Perhaps this is one interpretation of the results of a study that shows that patients who are prescribed antibiotics are more likely to re-attend for a subsequent sore throat. 4 Patients may also be interested in empirical information, (the effect of antibiotics on

sore throat: finite but small, for example[Del Mar, 1997 #4889). Certainly the empirical evidence of adverse reactions to antibiotics (thrush, diarrhoea and rashes) are well represented by both groups. Pharmacists are more likely to address precautions and interactions than GPs, (perhaps merely a reflection of the fact that GPs will already have the information gathered about what the patient is using already). Nearly 40% of pharmacists but many fewer GPs talk about the importance of rest. There is actually little evidence for or against rest for sore throat. Perhaps, like the manifestation of this advicebed-restfor other illnesses, one day it will be found to be wrong, 5 and that keeping going is the best advice after all. Pharmacists appear to be more likely to use classic safety netting[6] in the form of If the condition worsens (38% GPs compared to 82% pharmacists). I wonder if it might be that GPs do so just as, or more, often, but being such an integral part of their way of counselling, they do not think to articulate it in a survey. The public health aspects of the case are well supported: both GPs and pharmacists are inclined to talk about antibiotic resistance, and a quarter of GPs bother to tell patients about the risk of infecting others. The best way of avoiding this may be to wash hands more often, if the advice for other upper respiratory infections applies for this subset. 7 9 Professor Andrew Gilbert

School of Pharmacy and Medical Sciences, University of South Australia What non-pharmacological therapy would you recommend? The presenting symptoms of rhinosinusitis, acute sore throat, dry cough, headache, purulent nasal discharge and general malaise lasting for 3 days are indicative of a viral infection. An evidence based approach indicates no benefit from antibiotic therapy in terms of duration of the infection and recommends symptomatic management. An assessment of the patients symptoms as well as questioning in relation to history with this type of infection, treatments already tried (either with past infections or for this current episode), other medical conditions and any other medicines currently in use should be conducted prior to recommending therapy. The recommendations by both pharmacists and GPs are consistent with good management practices. Rest, fluids, particularly in the early stages of the infection, and steam inhalations are the key options in speeding recovery and assisting with the current symptoms associated with the sinus infection. The use of saline gargle and nasal inhalation was also recommended. There is evidence that saline inhalations are at least as effective as topical sympathomimetics. It is interesting that the pharmacists placed greater emphasis than the GPs on lifestyle advice (reducing stress, alcohol intake and smoking) and on multiple strategies. What drug therapy would you recommend? In general the choices of products by both pharmacists and GPs appear appropriate. The most obvious treatment is the management of pain (both headache and sore throat) with analgesics. In the absence of any contraindications or interactions, the range of analgesics offered also seems appropriate. The recommendation of aspirin and ibuprofen would need to be accompanied by consideration of conditions such as

asthma and also any past allergic reactions. It is interesting that only 65% of GPs recommended analgesics. The use of oral and topical decongestants is not unexpected and their use, with appropriate counselling, can provide good symptomatic relief. Cough suppressants, such as dextromethorphan, may have a place if the cough is severe and disturbing sleep. These products should not be used in children or when the cough is productive. Pharmacists were more likely to recommend saline nasal spray and the evidence indicates that this is at least as effective as sympathomimetics. They were also much more likely to have recommended a throat lozenge. It is true that anything sucked or chewed helps stimulate saliva production which in turn eases the sore throat. There is very little evidence that medicated products have any greater effect than nonmedicated lozenge, but are probably a harmless (albeit expensive) pleasant tasting placebo. Zinc was a popular choice in the complementary medicines section and lozenge containing zinc may have some benefit in shortening the duration of symptoms. Sucking a zinc containing lozenge every few hours delivers a relatively high dose of zinc and patients should be warned against long term use as the zinc will interfere with other metals such as copper. 10 Other popular complementary products included vitamin C and echinacea. There is some evidence that vitamin C, in a dose of 1G/day can shorten the duration of symptoms, particularly in patients with low levels of vitamin C such as smokers. There is also some evidence that echinacea helps reduce symptoms if used at the first signs of a cold. Caution must be exercised in the use of this product in people with asthma.

From the data provided to me it seemed likely that both pharmacists and GPs were recommending combinations of products. I could not tell whether these were rational combinations, but care should be exercised to ensure that pharmacologically these combinations made sense. What counselling would you provide regarding use of drug therapy? From the data provided it appears that the pharmacists routinely counselled patients on correct use of recommended medications and duration of use. Only one third of pharmacists provided advise on common side effects and even fewer explained contraindications, considered patients concerns or advised on parallel use of non-drug strategies. It appears from the data that counselling by GPs was a relatively infrequent event, with less than 50% of GPs explaining duration of use and less than one third explaining correct use. This may be an artifact of the way the data is reported or an expectation on the GPs part that the pharmacist will provide counselling. Given that more and more of these products are sold in supermarkets, this assumption is cause for concern. Prior to recommending any medication patients should be asked about other medical conditions, other medications they are using and any known sensitivities or allergies. If the medication is appropriate then, prior to use, the patient should be routinely provided with the following information on their medicines: 1. Its name and what it is for 2. How to take it (dose and duration of use) 3. What to expect from it (how soon it should have an effect , side effects that may be experienced and what to do if the condition does not improve or if it worsens)

4. Any precautions (for example interactions with alcohol or other medications) 5. Additional information that a patient may require to use the medicine safely and effectively. What information would you provide regarding the illness? The responses to this question again seem very reasonable. It appears that most pharmacists and GPs would offer reassurance and additional information to the patient. It is significant that the GPs emphasised that if the condition worsens the patient should see a doctor. This is important information that should be a routine part of the pharmacists advice to patients. What information would you provide regarding antibiotic therapy? 11 The responses to this question are also very sensible. The pharmacists appear more likely than the GPs to speak to patients both about the lack of benefit of antibiotics for this condition and the risks associated with their use. In terms of empowering consumers and enabling them to participate in the decision making processes it is important that they have access to complete information on the medicines they use. In summary Mr Frankston, in common with most people with viral upper respiratory tract infections, does not need medication. His condition is self-limiting with a usual time course of 4-14 days. Rest and warm fluids are helpful and paracetamol will help with management of symptoms such as headache and sore throat. Cigarette smoking, consumption of alcohol and late nights should be avoided. If medications are provided for symptomatic relief of nasal congestion and dry cough it is essential that the health practitioner assesses their suitability for us by Mr Frankston and provides

information to aid him use them safely and effectively