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A Practical Approach to Managing Respiratory Tract Infections in the Era of COVID-19 and Virtual Care: How can we continue to use antibiotics wisely? - Shared screen with speaker view
Sofia Nastis
Are there any clinical pearls you can provide GPs on modifying the centor criteria to consider supportive versus antibacterial treatment of pharyngitis if we are unable to swab our patients?
Guylene Theriault
The 3% that said yes can you explain?
Anne Sorensen
No outpatient Xray is allowing patients to book for cough/fever/ covid sx at this point so where would a CXR be ordered?
Guylene Theriault
Why was a CXR ordered? What were her vitals?
Kimberly Wintemute
I think availability of CXR is jurisdiction-dependent
Kimberly Wintemute
Certainly we have a lot of differences in practice in different parts of the country right now!
Christie Newton
Yes, and COVID negative would allow outpatient CXR
Kimberly Wintemute
I think you’re in Vancouver, right Christie?
allan grill
In my community, CXRs can be ordered for symptomatic patients. I work in Markham, ON
Christie Newton
Yes, BC but also variable across health authorities
Kimberly Wintemute
Right. CXR would be available in Toronto where I am. But I appreciate this is not the case everywhere.
Guylene Theriault
I don’t think I would have ordered an Xray if her vitals were normal
Christie Newton
@Guylene - Agreed
Jaana Ranchithan, CWC
Please feel free to enter your questions and comments into the Chat box.
Dr. J. Lawrence Gitterman
is this webinar mainpro certified ?
Jaana Ranchithan, CWC
@Dr. J Lawrence Gitterman- This webinar is not accredited for Mainpro+ credits.
Kimberly Wintemute
Although one could definitely do a “Linking Learning to Practice” exercise through CFPC for credits, after the webinar
Kathleen Doobay (She/Her) @kat_leeny
This is such an important learning, thank you! Appreciated the case analysis for context. Plus, it was fun too!
Suzanne Singh
will the viral prescription be updated to include COVID?
allan grill
We recognize that practice is not consistent across Canada in terms of resource availability. This tool is meant to help deal with these challenges get, but clinical judgment is highly respected.
Guylene Theriault
In Cochrane there is actually no satisfaction difference between non PX, Delayed Px and PX
Kathleen Doobay (She/Her) @kat_leeny
Noted digitally on Twitter. Good point Dr. Allan Grill
Andrea Stern
The patients I have difficulty with are patients with COPD patients who are having an exacerbation. How do I tell who needs & who doesn't need antibiotics? I have erred on the side of no antibiotics only to have a few patients land in the ER.
Guylene Theriault
This information is coming
Guylene Theriault
@Andrea look here https://choosingwiselycanada.org/campaign/antibiotics-primary-care
Guylene Theriault
Question: How common are secondary bacterial infection in COVID?
Andrea Stern
If they are that sick wouldn't they be better served in the ER? If someone is suspected of having Covid we don't see them until they have a negative covid test but it is now taking 5-7 days to get results. If they are that sick this is too long to wait to be seen.
Bradley Langford
Co-infection and secondary infection are relatively uncommon even in hospitalized COVID-19 patients, but risk increases with severity (higher risk in ICU) or patients who have been hospitalized for some time. We recently published a meta-analysis on this topic: https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(20)30423-7/fulltext
Salma Kassam
Will the slides be available to us after the presentation?
Jaana Ranchithan, CWC
@Salma Kassam: This webinar is being recorded and will be available on the Choosing Wisely Canada website.
Guylene Theriault
@Bradley thanks for the reference
allan grill
@Andrea Stern - good question. The decision to send someone to the ER is based on your clinical judgment. If their symptoms are not severe, they could be seen in-person in a less acute setting depending on your jurisdiction. Also, in the case of suspected OM, consider a delayed Rx if setting up an in-person assessment is difficult. The toolkit gives advice on this and Dr. Leis just reviewed it. Hope that helps.
Sofia Nastis
When it comes to managing patients over a virtual care platform who are unattached and without a GP, how do we get a patient swabbed for GAS if we suspect bacterial pharyngitis?
allan grill
Thanks @Bradley Langford - that’s why we set up the algorithm to think about COVID-19 status AND other possible RTI diagnoses given we don’t have access to immediate COVID-19 tests.
Anne Sorensen
What are local options as we are not seeing any people with fever in our building (shared with pharmacy/dentist/audiologist etc) and I don’t believe any local urgent cares are seeing anyone other than via phone (not letting people in with a fever etc)- where to send other than emergency which will become overloaded??
Kimberly Wintemute
For anyone working in COvid Centre, if you do not have rapid strep (we don’t) in your setting, I think it might makes sense to instruct pt to see their family MD if CoVid negative. Certainly strep and mono can present so similarly - I think we need to ensure throat swabs before giving antibiotics these days
allan grill
Thanks @Sofia - in the Patient Medical Home model, supported by the CFPC, the key is collaborating with your community partners like the ER, walk-in clinics or other primary care colleagues whose offices are open to in-person assessments to get the patient the care they need. We are all in this together and should support each other. It’s definitely a challenge!
Kimberly Wintemute
Anne Sorensen - looks like you are in quite a pickle. Can pts with fever get a cover test first, then be seen if negative?
Kimberly Wintemute
*CoVid test
allan grill
Thanks @Anne Sorensen - see my previous answer about leveraging community partnerships where available. But it is a great point.
allan grill
This audience is on the ball!
Anne Sorensen
We don’t allow anyone with fever and anyone with covid sx (even if negative test) and we are unable to send to Xray or lab if fever/ unwell ….so present default is if severe enough needs to go to the hospital- frustrating though but it is a building entry mandate
Jaana Ranchithan, CWC
Please feel free to enter your questions for Dr. Leis and Dr. Grill into the Chat.
Kathleen Doobay (She/Her) @kat_leeny
Enjoying the learning & the chat!
allan grill
My ER colleagues have been very understanding about primary care providers sending certain patients that we would normally manage pre-covid. This is a good time to build relationships with them if not already done so. #Patient MedicalHome
Jaana Ranchithan, CWC
Andrea Stern
Will pharmacies accept prescriptions emailed to patients?
Kimberly Wintemute
Yes, they do
Kimberly Wintemute
Again - in my local area they do. Shoppers is good about it
Guylene Theriault
In Quebec they prefer no paper. But here we are taking about a viral prescription. Nothing specific for the pharmacist
Elliot Lass
At what point in the outpatient setting, if at all should we recommend a repeat COVID test to determine if there was a false negative?
Kathleen Doobay (She/Her) @kat_leeny
Good Question Andrea. It depends on the pharmacist. Some still do fax whilst others do offer digital.
allan grill
@Elliott Lass - great question. We will cover this in the Q&A
Heather W
At my workplace we fax Rx from the EMR or ePrescribe using PrescribeIt (also in the EMR). No paper Rxs or email.
allan grill
Thanks @Heather W - same with my practice.
Andrea Stern
I'm not referring to Rx faxed from my office but if I email a Rx to a patient which they print off. Will pharmacies accept Rx that are not originals from patients.?
Kimberly Wintemute
Do the swab and wait for result is no problem also - risk of post-strep GN and RF not affected by 2-3 day time lapse
allan grill
Great point @KImberly
Rita Ha
@Andrea Stern. I think the pharmacy would need to be able to verify authenticity of the RX. If your office faxes or emails the RX to the pharmacy, it can be verified to come from your office. It would be harder to verify RX if printed from patient's own email. They could have created and sent themselves a RX.
Kimberly Wintemute
If you are working at a Covid Centre, please ensure a 10-15 second NP swab to reduce the chance of false negative! A quick in and out might be about as good as waving the swab in the air :)
Suzanne Singh
how will people handle cases where there may be elderly patients where you want to test for influenza and COVID? while awaiting results - how do you decide around oseltamivir?
Elliot Lass
Thanks Dr. Leis. And agreed with you Dr. Wintemute. I try to keep the NP swab in the nasopharynx as long as possible but for some unwilling participants (children especially), it is very challenging to do so.
Guylene Theriault
I put a note on the px and it works well
Heather McCarrel
if a patient presents with fever and sore throat and you assess in person and the swab is positive for strep, would you also suggest a covid test or are co-infections low enough you would presume strep was the cause of the symptoms? Ie what if parent asks if child can now return to school once strep is treated
Kathleen Doobay (She/Her) @kat_leeny
In the era of virtual care & COVID-19. Filled with change; shaping how we approach health including community partnerships… life changing & saving lives. You are all heroes! Thank you for today’s learning. Stay safe all.
Elliot Lass
At our Assessment Centre, we have the spit tests that we use for children, but the sensitivity/specificity is poor compared to the NP swab.
Loren Regier
Great session!!!
Terri Weinberg
thank you.
Kimberly Wintemute
Thanks for doing that, Doreen And thanks to Dr. Leis, Dr. Grill, Dr. Thériault and all the docs of the CWC Family Med Advisory Group for all this work. Great tool! And great discussion
Dominique Carrier
Thanks !
Carolyn Malec
At our assessment clinic- EVERYONE gets a NP swab- even babies. Anyone with red flag symptoms is assessed by a MD. great session- took many screen shots that I will share!
Kimberly Wintemute
To all our Primary Care colleagues - Keep Calm and Carry On!
Heather W
Thanks so much
Elliot Lass
Agreed, we encourage the NP swabs as much as possible for everyone
Elliot Lass
Thanks everyone. Great discussion and awesome timely toolkit.
Jaana Ranchithan, CWC
Please send any additional questions to: info@choosingwiselycanada.org