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A Family Physician's Perspective on Picornavirus Infections in Primary Care
Arch Fam Med. 2000;9:921-922.
AS A FAMILY PHYSICIAN and surveyor of viruses in the community, I and colleagues in the Communicable Diseases section of the Wisconsin State Laboratory of Hygiene bisect the year into the respiratory virus season—October through May—and the enterovirus season. The Picornaviridae, named for their small size and their ribonucleic acid genomes, encompass both seasons and include the rhinoviruses (HRV), enteroviruses (EV) (polioviruses, coxsackieviruses, echoviruses, enteroviruses), and hepatitis A virus. After investing considerable time in community surveillance and resident education on the role of viruses in primary care practice, I am happy to see increasing attention directed toward these most common disorders and their etiologic agents, as has been nicely provided in the article of Rotbart and Hayden1 on picornaviruses.
The common cold was named well. Rhinovirus infections are ubiquitous in humans. For example, the Seattle Virus Watch program provided estimates of population-wide infection rates of 0.59 HRV infections per person per year.2 It is of no surprise therefore, that there are 2800 cold remedies on the market.
Good epidemiological studies have demonstrated the high frequency of HRV in sufferers of the common cold, with estimates that 50% of common cold episodes are attributable to HRV.3 Their associations with other diagnoses in primary care, such as sinusitis, otitis media, and asthma exacerbations are well known. More importantly, discolored nasal discharge and postnasal drainage, common attributes of HRV infection, are significantly associated with antibiotic prescribing by family physicians.4 Consequently, antibiotic prescribing continues to occur at high frequencies for viral respiratory tract infections, contributing to emerging resistance patterns.
Educational efforts, especially in the recognition of the role of HRV infection in acute otitis media, sinusitis, lower respiratory tract symptoms, and acute exacerbation of asthma, are invaluable in the practice of evidence-based medicine. The information summarized by Rotbart and Hayden1 and the references included provide an excellent background to clinical situations faced daily by family physicians.
Enterovirus infections in primary care present greater challenges because of their widespread manifestations. Moreover, the same serotype may produce differing clinical manifestations in different patients.5 Infections, as noted by the authors, occur over a wide spectrum, from inapparent infections and isolated febrile episodes to significant myocarditis, aseptic meningitis, and encephalitis. Fortunately, the serious infections are rare in primary care practice. Diagnostic testing for EV infections is also rare in family practice settings, and largely conducted in cases of aseptic meningitis or more serious illnesses.
In reviewing the clinical significance, diagnosis, prophylaxis, and treatment of picornavirus infections, it is crucial to distinguish between commonness and seriousness in primary care medicine and to explore the context in which people with benign illness present to their physicians. During the past 4 respiratory virus seasons, 61,551 specimens obtained from patients with acute respiratory illnesses were processed and cultured in Wisconsin virus laboratories. Of these, HRV accounted for 940 positive cultures (1.5%). Of 19,072 positive cultures for any respiratory virus, HRV accounted for 4.9%. Nevertheless, the weekly prevalence can run as high as 69% of all positive virus cultures, underscoring the hyperendemic to epidemic occurrences of HRV. Of viruses originating in patients ill enough to warrant diagnostic culture (rare) or surveillance (common), HRV infection in family practice settings tends to occur on a similar frequency with parainfluenza viruses. Comparable information is not yet available for EV infections.
A recent study by McIsaac et al6 evaluated adult visits to physicians for common colds. Only 14% of cold sufferers consulted with their physicians. Significant predictors of visitation included not taking an over-the-counter medication, having 3 or more "sick days," living in larger households, not completing high school, and being unhappy. Susceptibility to experimental doses of HRV was inversely associated with the level and diversity of one's social network.7 Psychological stress has also been associated, in a dose-response relationship, with susceptibility to HRV infection.8 In the current paradigm, patient visitation in primary care for benign viral illnesses can be seen as a possible marker for other psychosocial issues, such as stress, isolation, or lack of education.
The development of novel antivirals9-10 such as pleconaril for treatment and for possible prophylaxis of HRV and EV infections poses an interesting dilemma for family physicians. Whereas effective treatments are always welcome, especially in cases of serious EV infections, the provision of antiviral agents may have the untoward effect of "medicalization"11 of the common cold. For example, prescribing an antibiotic for a sore throat primarily resulted in increased revisitations of patients for sore throats.12 Unless new therapeutic agents are destined for over-the-counter use, their introduction may result in many more visits to family physicians for antiviral prescriptions. Moreover, appropriate use of antiviral drugs is complicated by the shifting prevalence of etiologic agents in the community and the unavailability of cost-effective, rapid diagnostic tests in the ambulatory setting.
Such treatments may also change the focus of the patient visit. My interactions with patients around uncomplicated acute respiratory infections often include assessments of home, work, and family situations. It is a chance to assess the psychosocial well-being of my patient, to educate on transmission, hand-washing, and hygiene, and to provide anticipatory guidance.13-14
Infections attributable to HRV and EV are commonly seen in primary care practice. They are associated with common syndromes. We prescribe too many antibiotics for these syndromes. Family physicians should have some basic knowledge of their clinical manifestations, epidemiological distribution, and appropriate treatment. To this end, this "Primer for Practitioners" on Picornaviridae infections is needed and welcomed. I disagree, however, with the authors on 1 major point: "[Frequent antibiotic use for common colds and the related antibiotic resistance in bacteria] emphasizes the need for effective prophylaxis and treatment of HRV infections."1 Education, not medication, of our patients and health care providers can significantly reduce inappropriate antibiotic use without diminishing patient satisfaction.15-16 Improvements in the recognition of the role of viruses in our communities and practices can and should occur through publication of current reviews,1 education, and use of nonproprietary public health-based viral surveillance (eg, the National Respiratory and Enteric Virus Surveillance System [http://www.cdc.gov/ncidod/dvrd/nrevss]).
Jonathan L. Temte, MD, PhD
Department of Family Medicine
University of Wisconsin
777 S Mills St
Madison, WI 53715
REFERENCES
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1. Rotbart HA, Hayden FG. Picornavirus infections: a primer for the practitioner. Arch Fam Med. 2000;9:913-920.
FREE FULL TEXT
2. Cooney MK, Hall CE, Fox JP. The Seattle Virus Watch, III: evaluation of isolation methods and summary of infections detected by virus isolations. Am J Epidemiol. 1972;96:286-305.
FREE FULL TEXT
3. Makela MJ, Puhakka T, Ruuskanen O, et al. Viruses and bacteria in the etiology of the common cold. J Clin Microbiol. 1998;36:539-542.
FREE FULL TEXT
4. Dosh SA, Hickner JM, Mainous AG, Ebell MH. Predictors of antibiotic prescribing for nonspecific upper respiratory infections, acute bronchitis, and acute sinusitis. J Fam Pract. 2000;49:407-414.
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5. Melnick JL. Poliovirus and other enteroviruses. In: Evans AS, Kaslov RA, eds. Viral Infections of Humans. 4th ed. New York, NY: Plenum Medical Books; 1997:chap 21.
6. McIsaac WJ, Levine N, Goel V. Visits by adults to family physicians for the common cold. J Fam Pract. 1998;47:366-369.
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7. Cohen S, Doyle WE, Sooner DP, et al. Social ties and susceptibility to the common cold. JAMA. 1997;277:1940-1944.
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8. Cohen S, Tyrrell DA, Smith AP. Psychological stress and susceptibility to the common cold. N Engl J Med. 1991;325:606-612.
ABSTRACT
9. Pevear DC, Tull TM, Seipel ME, Groarke JM. Activity of pleconaril against enteroviruses. Antimicrob Agents Chemother. 1999;43:2109-2115.
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10. Turner RB, Wecker MT, Pohl G, et al. Efficacy of tremacamra, a soluble intercellular adhesion molecule 1, for experimental rhinovirus infection: a randomized clinical trial. JAMA. 1999;281:1797-1804.
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11. Herz MJ. Antibiotics and the adult sore throat: an unnecessary ceremony. Fam Pract. 1988;5:196-199.
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12. Little P, Gould C, Williamson I, et al. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ. 1997;315:350-352.
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13. Marcy SM. When a parent insists on antibiotics for a virus. Am Fam Physician. 1999;59:687-688.
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14. Temte JL. Antibiotic therapy for viral infections in children [letter]. Am Fam Physician. 1999;60:1932.
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15. Temte JL, Shult PA, Kirk CJ, Amspaugh J. Effects of viral respiratory disease education and surveillance on antibiotic prescribing. Fam Med. 1999;31:101-106.
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16. Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infection. Are patients more satisfied when expectations are met? J Fam Pract. 1996;43:56-62.
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