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Rick Knows Best: Challenging the Joint Commission
Richard Bukata, MD
December 29, 2009
Great presentation, Rick. The 14 minutes I listened was time well spent. Thanks.
The rapid strep test has a false negative rate of about 20%
With a false negative rate of 20%, rapid strep tests that are negative need culuture follow up.
Giving antibiotics based on clinical criteria alone has been shown in many studies to either over or undertreat.
We are not giving them water or a placebo, we are giving antibiotics with significant risk of allergic reactions and other side effects. Sometimes, such risks must be taken, but not when there are ways to avoid the risk, namely a throat culture.
Throat cultures are the gold standard. Not using them for patients with negative antigen tests is just bad medicine! The manufacturers are not just covering their butts, they know the limitations of their product as does the AAP AAFP.
CHUCK, your comments are ridiculous and belong on an AAP website. Emergency medicine needs to be pragmatic. Here is a disease which is almost always self-limited. Clinical treatment will find most cases, and it's not certainly not clear that benefits of ten days of PCN are outweighed by the many allergic reactions, GI concerns, and increased cost. "BAD MEDICINE" INDEED! You obviously put no mental power behind your comments which, I am sure, are just a recitation of some AAP guideline. Your comments highlight much of what is wrong with medicine.
Dear, M.D. it helps no one to engage in personal attacks and insults. Stick to the topicand can the "I am superior" rhetoric.
Your personal insults are not productive in any way and I ask that you please refrain from them in the future.
It makes no sense to have different standards for treating Group A BHS in the ER or the private practice office. The AAP standard you so quickly ridicule is quoted in the CDC Get Smart Page (tsmart/campaig
Furthermore, AAFP (http://www.aafp.org/afp/2001/0415/p1557.html) states a culture should be done for negative antigen tests.
Weather it is stated by AAP, AAFP, AHA or CDC, the recommendation to do a follow up culture is being made by almost all of the top ID doctors in this country. To set a unique ER standard that goes against this makes no sense to me at all. I also think that saying GABHS disease is almost always self limited ignores the many complications such as Rheumatic fever and post strep glomerulonephri
tis, to name only a few.
I have no problem with anybody having a different point of view on this topic and I certainly would not insult those who do. However, I believe my opinion that follow up cultures should be done is based on sound science and is the majority opinion of those doctors in this country who use rapid antigen tests.
Joseph Soler MD ABEM
Thank you. Excellent presentation. I usually treat clinically and save the patient a great deal of money. If all the "recommendation
s" are followed, the cost for a simple "pharyngitis" would be close to $600 (added labs $200 hospital facility charge ER physician charge).
If there is doubt as to whether treatment with antibiotic is needed or not, then do what the British advocate and give the patient a SNAP prescription (Safety Net Antibiotic Prescription), which the patient can decide to use or not based on his/her symptoms progression or lack of it. This approach reduces antibiotic usage by 15% while effectively reducing the cost of medical care.
This is a classic example of a disconnect between common sense and bureaucracy which adds a great economic burden for patients.
Read David Neuman's article about treatment of strep and the comments section discussing some of the issues raised here.
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