Respiratory Infection Practice Standard Summary
The Respiratory Infection (RI) Practice Standard supports the diagnosis and treatment of respiratory infection conditions. These include COVID-19, upper respiratory infection, bronchitis, sinusitis, pharyngitis, pertussis, influenza, pneumonia, subacute cough due to post nasal drip, bronchospasm, or GERD, and chronic cough.
Background
The RI Practice Standard will launch if all of the following criteria are met:
Patient is between the ages of 18 and 64
Based on the patient’s Chief Complaint, the diagnoses presented for the provider’s consideration by machine learning relate to COVID-19, upper respiratory infection, bronchitis, sinusitis, pharyngitis, influenza, pneumonia, or pharyngitis
Clinical Content
Medical Interview Summary
The RI Practice Standard starts by asking every patient about COVID-19: vaccinations, past infection history, recent exposure and recent test results. It then asks about annual flu vaccination history and the interview splits based on whether they are symptomatic or asymptomatic. Symptomatic patients will receive questions about respiratory symptoms, while asymptomatic patients will receive questions about COVID-19 or influenza exposure, depending on the circumstance.
A standard set of questions is asked of all symptomatic patients, in order to obtain a basic review of the fundamental respiratory systems (duration since onset of symptoms, constitutional, sinuses, throat, chest). Conditional follow up questions may be asked (e.g. if a patient reports a cough, it will ask about duration and sputum production).
If the patient reports shortness of breath, the RI Practice Standard asks about red flags, such as dyspnea with daily activity, dyspnea with light activity, and difficulty speaking full sentences. Some symptom clusters warrant a referral to urgent care or the emergency department, such as shortness of breath, fever, sweats, chills, productive cough, and chest pain which are concerning for pneumonia. Some symptom clusters warrant a referral to in person primary care or urgent care for testing instead of empiric treatment, such as intermediate probability Centor scores and intermediate likelihood of influenza when treatment may be recommended with a positive rapid influenza test.
At the end of the automated interview, a diagnosis will be presented for the provider’s consideration, along with relevant prescription medication(s), and documentation to support the provider’s medical decision making. In addition, referrals and lab suggestions will be displayed. Some symptom combinations will recommend in person exam or testing. Based on the diagnosis selected by the provider, some care plans will be entered in for the patient’s education. In cases like sinusitis where there is the possibility of having a bacterial or viral cause, the care plan will be imported by the provider in the form of a text expander. A reminder in the console will tell the provider whether they have to import their own care plan. The provider can choose to use the suggestions provided, or change them based on their clinical decision making.
Virtual Care Management Pearls
Acute sinusitis, bacterial
Bacterial sinusitis symptoms include the following
Sinus pressure and nasal congestion lasting ≥10 days
Sinus pressure and nasal congestion lasting 8-10 days with double-sickening and either increased nasal secretions, fever, or sinus headache worsening with bending forward
Nasal discharge amount or color should not influence diagnosis
Acute sinusitis, viral
Viral sinusitis symptoms include the following
Sinus pressure and nasal congestion without sore throat, cough, shortness of breath, chest pain and:
Symptom onset <10 days
Most sinusitis infections are viral
Nasal discharge amount or color should not influence diagnosis
Note that most other acute combined symptoms (sinus pressure and congestion with other symptoms such as sore throat or cough) are often diagnosed as URI
Acute Upper Respiratory Infection (URI)
Suspect in patients in which a mix of sinus, pharyngeal, or lower airway symptoms are present
Nasal discharge amount or color should not influence diagnosis
Most symptomatic respiratory infections that do not satisfy the specific diagnostic criteria for the other diagnoses in the RI Practice Standard are diagnosed as acute URI
Acute Bronchitis
Suspect in patients with cough for 2-3 weeks, with mild lower respiratory symptoms not concerning for pneumonia
Sputum production, amount, or color should not influence diagnosis
COVID-19 positive, symptomatic
COVID-19 positive by at-home or NAAT testing history:
The RI Practice Standard assesses if the patient may be a candidate for oral antiviral medication using age, race/ethnicity, vaccination history, duration of symptoms and questions about medical conditions that put them at high risk for complications from COVID-19 infection, following CDC guidance
If oral antiviral treatment criteria are satisfied, the RI Practice Standard will present for consideration treatment with paxlovid or molnupiravir, and provide chat suggestions for the clinician to confirm current medications during the visit, for safe prescribing of the oral antiviral options
COVID-19 positive, asymptomatic
COVID-19 positive by at-home or NAAT testing history, asymptomatic
Antiviral treatment not recommended
COVID-19 exposed, asymptomatic
Asymptomatic, exposed by CDC criteria, COVID-19 negative by at-home or NAAT testing history, or untested
COVID-19 concerns, symptomatic, not positive
Symptomatic, COVID-19 negative by at-home or NAAT testing history, or untested:
Suspect possible COVID-19 in most symptomatic respiratory infection patients
Common symptoms include fever, chills, cough, shortness of breath, fatigue, sore throat, runny nose, congestion, body aches, headache, vomiting, diarrhea, loss of smell and taste, COVID-19 exposure, and slower development of symptoms
Influenza
Asymptomatic influenza exposure
Antiviral post-exposure prophylaxis treatment is recommended when all of these are true:
Asymptomatic
First influenza exposure ≤48 hours ago
High medical risk for severe complications from influenza
No flu shot, or flu shot received <2 weeks prior
Symptomatic possible influenza
The RI Practice Standard uses all combinations of the following criteria to categorize into evaluation and treatment categories
Influenza “seasons” of the year
Peak-season: December, January, February
Shoulder-season: October, November, March, April, May
Off-season: June, July, August, September
Exposure to influenza
Duration since onset of symptoms
Clinical likelihood that symptoms are consistent with influenza infection
A clinical decision rule identifies symptoms to determine influenza likelihood
2 points for fever + cough (no partial credit)
2 points for myalgias
1 point for duration <48h
1 point for chills/sweats
Scoring system:
0-2 points LOW (8%) flu likelihood
3 points MODERATE (30%) flu likelihood
4-6 points HIGH (59%) flu likelihood
Medical risk for severe complications from influenza infection
Assessment of age, race/ethnicity, and questions about medical conditions that put them at high risk for complications from Influenza infection.
The RI Practice Standard sorts all combinations of the criteria above into one of these categories:
Empiric treatment:
The highest likelihood and/or highest risk of influenza; empiric antiviral treatment is recommended
When empiric treatment is recommended, the patient is advised to start the medication as soon as possible, and is also advised to seek in person care for confirmatory influenza testing
Refer for testing:
Possible influenza, the patient may qualify for antiviral treatment, but an influenza test is needed to make that determination
These patients are referred to in person care for testing
No treatment and no referral:
These categories do not support antiviral treatment or testing
The RI Practice Standard will result in a different respiratory diagnosis, without any specific callout of influenza concerns
Pertussis
Overall symptom onset >10 days, cough duration 2-8 weeks, barking cough, coughing spasms / paroxysms
In suspected cases the patient is asked about exposure to pertussis
Pharyngitis
If a patient reports a sore throat, the RI Practice Standard may ask questions and calculate the Centor score, depending on the presence of other symptoms
For cases of possible strep throat, the RI Practice Standard will provide a chat suggestion for the clinician to ask for a photo of the throat during the clinician visit
Centor score 4: Possible strep throat, recommend empiric antibiotic treatment
Centor score 3: Refer for in-person care for strep testing
Centor score 2 and no sinus congestion, pressure, nasal discharge, conjunctivitis, new rash: Refer for in-person care for strep testing
Centor score 2 and any viral symptoms above: Non-pharyngitis diagnosis
Centor score 0-1 and no sinus congestion, pressure, nasal discharge, conjunctivitis, new rash: Viral pharyngitis
Centor score 1 and any viral symptoms above: Non-pharyngitis diagnosis
Pneumonia
Fever, productive cough, sweats/chills, and lower respiratory symptoms such as shortness of breath, tachypnea, chest pain
Concern for possible pneumonia needs an in person evaluation and / or chest imaging, and patients are not candidates for empiric treatment
The console suggests cough and refer to in person care given a diagnosis of pneumonia via telemedicine is difficult
Subacute cough
Cough duration 3-8 weeks
The RI Practice Standard asks about post-nasal drainage, wheezing, and acid reflux
Chronic Cough
Cough duration ≥8 weeks
Medication Guidelines
Acute sinusitis, bacterial
OTC recommendations noted in chat suggestions
Rx antibiotics:
Amoxicillin/clavulanate 875mg/125mg BID x 7 days (first line)
Doxycycline 100mg BID x 7 days (if pcn allergy)
Macrolides and trimethoprim-sulfamethoxazole are not recommended due to antibiotic resistance
Not recommended: Oral corticosteroids
Acute sinusitis, viral
OTC recommendations noted in chat suggestions
Rx: Optional benzonatate 100mg TID PRN #21 with guaifenesin
Not recommended: Antibiotics, oral corticosteroids
Acute Upper Respiratory Infection (URI)
OTC recommendations noted in chat suggestions
Rx: Optional benzonatate 100mg TID PRN #21 with guaifenesin
Not recommended: Antibiotics, oral corticosteroids
Acute Bronchitis
OTC recommendations noted in chat suggestions
Rx: Optional benzonatate 100mg TID PRN #21 with guaifenesin
Not recommended: Antibiotics
Not recommended: Oral or inhaled corticosteroids or albuterol inhaler (unless indicated for asthma or related pulmonary disease)
COVID-19 positive, symptomatic
OTC recommendations noted in chat suggestions
Rx: Optional benzonatate 100mg TID PRN #21 with guaifenesin
Rx with antiviral:
Paxlovid (EUA) 300 mg (150 mg x 2)-100 mg tablet, Take two 150 mg tablets of nirmatrelvir with one 100 mg tablet of ritonavir twice daily for 5 days (first line)
Molnupiravir 200 mg capsule (EUA), 4 caps by mouth every 12 hours for 5 days (second line if paxlovid is contraindicated)
Not recommended: Oral or inhaled corticosteroids (unless indicated for asthma or related pulmonary disease), non-proven treatments including antibacterials, hydroxychloroquine, ivermectin
COVID-19 positive, asymptomatic
Not recommended: Antiviral treatment, corticosteroids, non-proven treatments
COVID-19 exposed, asymptomatic
Not recommended: Prophylaxis, antiviral treatment, corticosteroids, non-proven treatments
COVID-19 concerns, symptomatic, not positive
Not recommended: Antiviral treatment, corticosteroids, non-proven treatments
Influenza asymptomatic post-exposure prophylaxis
Rx: Oseltamivir 75mg daily x 7 days
Influenza symptomatic
OTC recommendations noted in chat suggestions
Rx: Optional benzonatate 100mg TID PRN #21 with guaifenesin
Rx for “empiric treatment” recommendation:
Oseltamivir 75mg BID x 5 days (preferred)
Baloxavir 40mg (40-80kg) or 80mg (>80kg) single dose (alternate)
Pertussis symptomatic
Antibiotic treatment is not recommended without evaluation and testing
Pharyngitis
Empiric strep throat treatment:
OTC recommendations noted in chat suggestions
Rx:
Penicillin V 500mg BID x10 days (first line)
Amoxicillin 500mg BID x 10 days (second line)
If allergic to penicillins:
Cephalexin 500mg BID x 10 days
Azithromycin 500mg daily x 5 days
Not recommended: Oral corticosteroids
Viral pharyngitis:
OTC recommendations noted in chat suggestions
Not recommended: Antibiotics, oral corticosteroids
Subacute cough
Post nasal drainage
OTC recommendations noted in chat suggestions
OTC: Optional oxymetazoline maximum 3 days
Airway inflammation
Rx: Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, Inhale 2 puffs every 4 - 6 hours as needed for cough, wheezing, or shortness of breath
Acute or chronic GERD symptoms
OTC: Omeprazole 20mg daily for 2-4 weeks
Not recommended: Antibiotics, oral corticosteroids
Follow-up Recommendations to be Discussed with the Patient
Acute sinusitis, bacterial
Urgent care or emergency department:
Fever >102 for >5 days, vision changes, facial swelling or redness, worsening severe headache, confusion, disorientation, unusual sleepiness, stiff painful neck
Counsel on current CDC recommendations for isolation and COVID-19 testing
Acute sinusitis, viral
Follow up with our clinic
High persistent fevers, increasing sinus pain, overall worsening instead of improvement
Urgent care or emergency department:
Fever >102 for >5 days, vision changes, facial swelling or redness, worsening severe headache, confusion, disorientation, unusual sleepiness, stiff painful neck
Counsel on current CDC recommendations for isolation and COVID-19 testing
Acute Upper Respiratory Infection (URI)
Counsel on current CDC recommendations for isolation and COVID-19 testing
Acute Bronchitis
Follow up with our clinic or in person
Cough >3 weeks
Urgent care or emergency department
Fever >100.4 for >5 days, worsening shortness of breath
Counsel on current CDC recommendations for isolation and COVID-19 testing
Chronic cough
In person PCP
Referral for in person exam and possible chest X-ray
COVID-19 positive, symptomatic
Urgent care or emergency department
Pulse oximetry <94%
Positive answers to pulmonary red flag questions
Severe weakness or shortness of breath develops after visit
If paxlovid is recommended, chat suggestions are provided to clinicians describing paxlovid rebound and recommending re-isolation
Counsel on current CDC recommendations for isolation
Follow up if symptoms not resolving at end of recommended isolation
COVID-19 positive, asymptomatic
Counsel on current CDC recommendations for isolation
Re-isolate or continue isolation if symptoms develop
COVID-19 exposed, asymptomatic
Counsel on CDC recommendations for quarantine and testing
Isolate if symptoms develop
COVID-19 concerns, symptomatic, not positive
Counsel on current CDC recommendations for isolation and COVID-19 testing
Influenza exposure, asymptomatic:
Follow up with our clinic
If symptoms develop after visit, whether or not post-exposure prophylaxis is prescribed: fevers, chills, sweats, body aches, cough or other respiratory symptoms
Influenza symptomatic
Urgent care or emergency department
Pulse oximetry <94%
Positive answers to pulmonary red flag questions
In person PCP or urgent care
When treated with empiric antiviral, start antiviral right away and also refer for in-person testing for influenza and COVID-19 for confirmation
When not treated empirically with antiviral, but may qualify if influenza test is positive, refer for in-person testing for influenza and COVID-19
Counsel on current CDC recommendations for isolation and COVID-19 testing
Pertussis symptomatic
In person PCP
Referral for in person exam and testing
Suspected cases should be reported to the local Health Department prior to laboratory confirmation via in person provider
Pharyngitis
Urgent care or emergency department
If worsening sore throat, fever, difficulty breathing or swallowing saliva after visit
PCP or urgent care
If sore throat is not improving or is worse after 72 hours of empiric antibiotics for strep throat
If indeterminate strep throat, refer for strep testing
Follow up with us or PCP
If viral pharyngitis and sore throat persists >7 days
Counsel on current CDC recommendations for isolation and COVID-19 testing
Pneumonia
Urgent care
Referral for in person exam and possible chest X-ray
ICD-10 Codes Provided
Associated Available TextExpanders (if needed)
Please see your institution's Text Snippet document on available options.
Chat and Documentation Suggestions
In addition to presenting diagnostic and treatment suggestions for consideration by the provider, the RI Practice Standard presents chat and documentation suggestions to the provider for consideration based on previous machine learning.. The suggestions are tied to the selection of a diagnosis suggested for consideration by the provider. For example, if the RI Practice Standard suggests Acute Upper Respiratory Infection as the ICD-10 diagnosis AND the provider selects Acute Upper Respiratory Infection as their diagnosis, the chat and documentation suggestions for consideration will relate primarily to Acute Upper Respiratory diagnosis and treatment.
Citations
Centers for Disease Control and Prevention (2022, September 28). COVID-19 Testing: What You Need to Know. Centers for Disease Control and Prevention. Retrieved October 5, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html
Centers for Disease Control and Prevention (2021, Dec. 27). Healthcare Workers: Information on COVID-19. Retrieved October 5, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
Centers for Disease Control and Prevention (2022, June 27). Strep Throat: All You Need to Know. Retrieved October 5, 2022, from https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html#:~:text=Close%20contact%20with%20another%20person,other%20people%20in%20their%20household
Centers for Disease Control and Prevention (2022, September 30). Weekly US Map: Influenza Summary Update. Retrieved October 5, 2022, from https://www.cdc.gov/flu/weekly/usmap.htm
del Rio, C., MD, & Malani, P. N., MD (2020). COVID-19—New Insights on a Rapidly Changing Epidemic. JAMA. https://doi.org/10.1001/jama.2020.3072
Ebell, M. H., Afonso, A. M., Gonzales, R., Stein, J., Genton, B., & Senn, N. (2012). Development and validation of a clinical decision rule for the diagnosis of influenza. Journal of the American Board of Family Medicine : JABFM, 25(1), 55–62. https://doi.org/10.3122/jabfm.2012.01.110161
Fashner, J., Ericson, K., & Werner, S. (2012). Treatment of the common cold in children and adults. American family physician, 86(2), 153–159.
Meneghetti, A., MD, & Mosenifar, Z., MD, FACP, FCCP (2020, September 11). Upper Respiratory Tract Infection Treatment & Management. Medscape. Retrieved October 5, 2022, from https://emedicine.medscape.com/article/302460-treatment#d15
Puhakka, T., Mäkelä, M. J., Alanen, A., Kallio, T., Korsoff, L., Arstila, P., Leinonen, M., Pulkkinen, M., Suonpää, J., Mertsola, J., & Ruuskanen, O. (1998). Sinusitis in the common cold. The Journal of allergy and clinical immunology, 102(3), 403–408. https://doi.org/10.1016/s0091-6749(98)70127-7
Rettner, R. (2020). How does the new coronavirus compare with the flu? Live Science. Retrieved October 5, 2022, from https://www.livescience.com/new-coronavirus-compare-with-flu.html
Sheikh, K., Watkins, D., Wu, J., & Gröndahl, M. (2020, February 28). How Bad Will the Coronavirus Outbreak Get? Here Are 6 Key Factors. The New York Times. Retrieved October 5, 2022, from https://www.nytimes.com/interactive/2020/world/asia/china-coronavirus-contain.html
Smith, S. M., Schroeder, K., & Fahey, T. (2014). Over-the-counter (OTC) medications for acute cough in children and adults in community settings. The Cochrane database of systematic reviews, 2014(11), CD001831. https://doi.org/10.1002/14651858.CD001831.pub5