Choosing Wisely Urgent and Emergent Care James Poock, M.D., F.A.A.F.P.

9 year old boy presents with 1 day history of right ear pain 9 year old boy presents with 1 day history of right ear pain. Has had “a cold” for 2 – 3 days, elevated temperature of 100 degrees, rhinorrhea and cough. Physical exam reveals alert child in no acute distress, Vitals of 99.9 88 16 100/60, TM’s erythemous with middle ear fluid noted. Nose congested with clear mucous. Oropharynx moist, no erythema, neck supple, no LAD, Heart RRR, lungs CTA, no distress. What is the appropriate course of action? A: Amoxicillin 50 mg/kg divided BID x 7 days B: Amoxicillin 90 mg/kg divided BID x 7 days C: Azithromycin 10 mg/kg daily for 3 days D: Cefdinir 14mg/kg divided BID x 7 days E: Symptomatic relief with Tylenol, Motrin, and observation for 48 – 72 hours

Acute Otitis Media (AOM) is one of the most common infections in early infancy and childhood, causing pain and general symptoms of illness such as fever, irritability, and problems feeding and sleeping. By 3 years of age, most children have had at least 1 AOM episode. Though AOM usually resolves itself without treatment, it is often treated with antibiotics.

A review of the literature revealed that antibiotics were not very useful for most children with AOM. No decreased in pain at 24 hours (60% were better anyway). No decrease in pain at 3 – 7 or 11 – 14 days No decrease in AOM reoccurrences and hearing loss at 4 week and 3 months Only a slight decrease in the number of children with perforation of the eardrum (NNT 33) and AOM in the initially unaffected ear (NNT 11) at 3 months. No difference at 4 weeks.

Not enough evidence to know if antibiotics reduced rare complications such as mastoiditis Adverse events associated with antibiotic use included vomiting, diarrhea and rash (NNH 14)

Conclusion Clinical management of AOM should emphasize advice about adequate analgesia and the limited role for antibiotics. Antibiotics are most useful in children under 2 years of age with bilateral AOM or with both AOM and Otorrhea. For children in the U.S. an expectant observational approach seems justified.

A 27 year old woman presents with a 3 day history of nasal congestion, post nasal drip, and left sided facial pain worse with leaning forward. She states the mucous has turned from clear to green over the last day. She is a non-smoker. Physical exam reveals 98. 6 120/76 72 16. Nasal mucosa congested with clear mucous. Pain with palpitation on the left cheek and frontal sinus. Oral oropharynx with post nasal drip present but no erythema. Heart: RRR Lung: CTA. What is appropriate therapy? A: Amoxicillin 500 mg PO TID x 14 days B: Nasal saline washes, decongestants and Tylenol or NSAIDS for pain C: Referral for CT scan D: A &C E: All of the above

Sinusitis is an inflammation of the mucous membranes of the paranasal sinuses characterized by nasal congestion, purulent nasal discharge, headache, and facial pain. 98% of sinusitis is Viral URI Only 0.5% - 2% complication by bacterial rhinosinusitis In studies approximately 50% of all participants were cured in 1 week with antibiotic or placebo and 75% were cured after 14 days Antibiotics shortened time to cure in only 5 of 100 participants (NNT18) Adverse events (diarrhea, vomiting, rash) NNH 8 Very low serious complication rate in both groups

Indications for antibiotic therapy: Symptoms greater than 10 days Fever and purulent nasal discharge or facial pain last 3 -4 days Symptoms worsening after 7 days Immunosuppressive pharmacological therapy Antibiotic of choice in Augmentin Amoxicillin-Clavulanate for 7 days

A 54 year old male presents with complaint of a sore on his left abdominal wall that has been there a “few” days. No fevers, chills or sweats. No injury. Unsure how it got there. No significant family history and no medications. Physical exam: 98.6 138/78 80 12. There is a 2 – 3 CM fluctuant mass noted in the left periumbilical area. There is no surrounding erythema. What is the appropriate treatment for this abscess? A: I &D, wound culture, and Clindamycin 150mg QID x 7 days B: Bactrim DS divided BID for 7 days C: I&D alone with close follow up D: No treatment. Will resolve on own.

With increasing prevalence of MRSA there is concern that I&D may be insufficient treatment for skin abscesses. Double blind studies have shown that post I&D treatment with and without antibiotics had no difference in outcomes. (95% CI) Both antibiotic and placebo groups had a high rate (approximately 25%) of recurrence or development of new lesions at 10 days and 3 months (95% CI) In the treatment of abscesses, even those caused by MRSA, antibiotics provide no additional benefit if the abscess has been adequately drained and the patient has a well functioning immune system Culture of the abscess fluid is not needed as it will not routinely change treatment

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