In My Opinion
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Military and civilian medicine have always been intertwined, but nothing compares to the strange tale of Warren Air Force base in the 1940’s. Perched on the high plains outside of Cheyenne, Wyoming, the combat training center was, mysteriously, a bacterial cauldron. For more than a decade virulent strains of group A streptococcus caused unprecedented rates of pharyngitis among the trainees, and history’s worst epidemic of rheumatic fever.

A small cadré of military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory.

Prior to the epidemic at Warren Air Force base there was little interest in ‘strep throat’. During the twenties and thirties in the Unites States, sore throat care focused on diphtheria, “the strangling angel.” The characteristic ‘bull neck’ and the dreaded grey pseudomembrane led to a gruesome, asphyxiating death for thousands of children each year. Comparatively, strep throat was a minor nuisance that often received little more attention than the common cold. But by the 1940s vaccination programs had nearly eradicated diphtheria, and antibiotics were becoming widely available. When the Air Force studies were reported in the early 1950s, they resonated. Rheumatic heart disease was common among adults, making its prevention seem immediate and intuitively important, and antibiotics for a bacterial infection made good sense. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed.

The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely.

At Warren Air Force base only 50-60 recruits were treated to prevent one case. Today, preventing one case would likely require antibiotic treatment for hundreds of thousands of strep throats, making it a mathematical certainty that antibiotics will do more harm than good. For each case of rheumatic fever prevented in modern practice, a few dozen patients either die or suffer near-fatal anaphylaxis, toxic epidermal necrolysis, colitis, or other antibiotic reactions, and many thousands more suffer diarrhea, rashes, and yeast infections.

Fortunately, rheumatic fever has been declining for a century, starting well before the introduction of antibiotics. While strep throat is no less common today, ‘rheumatogenic’ strains have dwindled, leading epidemiologists to conclude that antibiotics have little or nothing to do with rheumatic fever’s disappearance. Changes in hygiene, nutrition, population crowding, access to care, and changes in the bacterium are all felt to be important factors, which explains why the disease is now typically seen most in third world settings.

There are, arguably, other reasons to consider antibiotics for pharyngitis, but the evidence does not rise to support them. The Cochrane group estimates a 16-hour reduction in symptoms with antibiotics, but ibuprofen, acetaminophen, or a single dose of corticosteroids is as good or better, with fewer side effects. And while peritonsillar abscess may be minimally reduced by antibiotics, abscesses typically present primarily rather than after strep throat, and in most cases are easily treated. No studies have shown that antibiotics reduce the transmission of strep or reduce other complications.

The administration of antibiotics for strep throat, endorsed universally by practice guidelines and professional societies, is based exclusively on data from the world’s most concentrated epidemic of rheumatic fever. Using this to guide modern therapy is like administering antibiotics to prevent bubonic plague.

The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.

David H. Newman is the author of
Hippocrates Shadow (Scribner $26)
Find more by Dr. Newman in upcoming issues of Emergency Physicians Monthly

 

Studies that captured rheumatic fever cases at WAF base:
Denny FW, Wannamaker LW, Brink WR. Prevention of rheumatic fever.  Treatment of the preceding streptococcic infection. JAMA. 1950;143(2):151-3.
Bennike T, Kjaer E, Skadhauge K, al e. Penicillin therapy in acute tonsillitis, phlegmonous tonsillitis, and ulcerative tonsillitis. Acta Media Scandinavia. 1951;139:253-74.
Brink WR, Rammelkamp CH, Denny FW, Wannamaker LW. Effect of penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis. Am J Med. 1951;10:300-8.
Denny FW, Hahn E. Comparative effects of penicillin, aureomycin, and terramycin on streptococcal tonsillitis and pharyngitis. Pediatrics. 1953;11:7-14.
Catanzaro F, Morris A, Chamovitz R, al e. Symposium on rheumatic fever and rhuematic heart disease. The role of Streptococcus in the pathogenesis of rheumatic fever. Am J Med. 1954;17:749-56.
Chamovitz R, Stetson C, Rammelkamp CH. Prevention of rheumatic fever by treatment of previous streptococcal infection. New Engl J Med. 1954;251:466-71.

CDC document last reporting the incidence of Acute Rheumatic Fever:
Centers for Disease Control and Prevention. Summary of notifiable diseases, United States, 1997. Mor Mortal Wkly Rep CDC Surveill Summ. 1998;46:1-87

Antibiotic side effects:
Rudolph AH, Price EV. Penicillin reactions among patients in venereal disease clinics: a national survey. JAMA. 1973;223:99-108.
Neugut A, Ghatak A, Miller R. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Int Med. 2001;161(1):15-21.
Idsoe O, Guthe T, Wilcox R, al e. Nature and extent of penicillin side-reactions, with particular reference to fatalities from anaphylactic shock. Bull WHO.1968; 38(2):159-88.
Roujeau J. Drug-induced toxic epidermal necrolysis II: Current aspects. Clin Derm. 1993;11:493-500.
Bachot N, Roujeau J. Physiopathology and treatment of severe drug eruptions. Current Op All Clin Imm. 2001;1(4):293-8.

Epidemiology of rheumatic fever and reasons for its decline:
Bronze MS, Dale JB. The reemergence of serious group A streptococcal infections and acute rheumatic fever. Am J Med Sci. 1996;311(1):41-54.
Stollerman GH. Rheumatic fever in the 21st century. Clin Inf Dis. 2001;33(6):806-14.
Quinn R. Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever. Rev Inf Dis. 1989;11(6):928-53.
Gordis L. The virtual disappearance of rheumatic fever in the United States: lessons in the rise and fall of disease. T. Duckett Jones memorial lecture. Circulation. 1985;72(6):1155-62.
Olivier C. Rheumatic fever - is it still a problem? J Antimic Chemo. 2000; 45:13-21.
Markowitz M. The decline of rheumatic fever: role of medical intervention. J Ped. 1985;106:545-50.

Studies demonstrating the impact of NSAIDs and steroids on pharyngitis
Middleton D, D’Amico F, Merenstein J. Standardized symptomatic treatment versus penicillin as initial therapy for streptococcal pharyngitis. J Ped. 1988;113(6):1089-94.
Bertin L, Pons G, d’Athis P, al e. Randomized, double-blind, multicenter, controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children. J Ped. 1991; 119(5):811-4.
Watson N, Nimmo W, Charlesworth C, al e. Relief of sore throat with the anti-inflammatory throat lozenge flurbiprofen 8.75 mg: a randomised, double-blind, placebo-controlled study of efficacy and safety. Int J Clin Pract. 2000;54(8):490-6.
O’Brien J, Meade J, Falk J. Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med. 1993;22:212-15.
Marvez-Valls E, Ernst A, Gray J, al e. The role of betamethasone in the treatment of acute exudative pharyngitis. Acad Emerg Med. 1998;5:567-72.
Wei J, Kasperbauer J, Weaver A, al e. Efficacy of a single-dose dexamethasone as adjuvant therapy for exudative pharyngitis. Laryngoscope. 2002;112:87-93.
Kiderman A, Yaphe J, Bregman J, et al. Adjuvant prednisone therapy in pharyngitis: a randomised controlled trial from general practice. Br J Gen Pract. 2005; 55(512): 218-21.
Olympia RP, Khine H, Avner JR. Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children. Arch Ped Adol Med. 2005; 159(3): 278-82.
Hahn R. Clinical evaluation of flurbiprofen alone and plus ampicillin in chronic pharyngitis in acute phase. International J Clin Pharm Res. 1986;6(1):81-6.

Review of peritonsillar abscess literature and epidemiology
Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Ann Emerg Med. 2001; 37(6): 711-719.
Savolainen S, Jousimies-Somer H, Makitie A, al e. Peritonsillar abscess: clinical and microbiologic aspects and treatment regimens. Arch Otol Head Neck Surg. 1993;119:521-4.
Passy V. Pathogenesis of peritonsillar abscess. Laryngoscope. 1994;104:185-90.

 
 

Comments   

# MDilene brenner 2009-03-09 18:27
What about post strep glomerulonephri tis? I thought that was the real reason we treat for strep. To prevent that.
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# Antibiotics May Not Reduce the Incidence of Glomerulonephri tisChris Carpenter 2009-03-10 19:47
The Cochrane Review on Abx for Strep Throat note no significant benefit for Abx in preventing glomerulonephri tis (http://pmid.us/17054126). "Cases of acute glomerulonephri tis only occurred in the control group which suggests protection by antibiotics. However, there were only TWO cases, and only ten studies reported on acute glomerulonephri tis as an end point. Therefore our estimate of the protection has a very wide 95% confidence interval (CI), (RR 0.22; 95% CI 0.02 to 2.08) which precludes us from definitively claiming that antibiotics protect sore throat sufferers from acute glomerulonephri tis."
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# MDERDoc 2009-03-11 08:51
What about retropharyngeal abscess? Not too common but these can be life threatening, and can form from local spreading. To discount the threat of abscess (peritonsillar or retropharyngeal ) seems a little bit of a stretch.

If I get strep or anyone in my family, I'll want antibiotics ten times out of ten.
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# Retropharyngeal Abscess (Quinsy)Chris Carpenter 2009-03-11 15:19
The Cochrane Review also addresses the prevention of quinsy within 2-months by treating strep throat with antibiotics. Based upon 8 trials between 1951-2000 with little heterogeneity they report a NNT = 46 to prevent one case of peritonsillar abscess. However, the incidence of quinsy in 2009 is lower than it was in 1950 so the NNT is likely higher than 46.
Based upon some of the most recent trials (1997, 2000) the NNT was 225 and 55, respectively. Additionally, one may be able to prevent otitis media with antibiotics with a NNT = 200 based upon current incidence patterns.

Ten-million antibiotic prescriptions are written for strep throat every year with the potential for 25,000 fatal allergic reactions and over one-million cases of diarrhea. Despite the fact that only one-third of RF patients suffered the dreaded long-term rheumatic heart disease, medical societies, ID experts, and renowned Cardiologists vocally advocated for RF prevention by aggressively treating all strep throat cases with antibiotics by the early 1960’s, a pseudoaxiom which continues to this day.

Look closely at these efficacy numbers relative to the incidence of RF today. In 1950, 98% of recruits did not contract RF regardless of whether or not they received antibiotics. Furthermore, despite antibiotics half of those who were treated still contracted RF. In 2007, an analysis of 30000 strep throat cases (some treated, others not) identified no cases of RF. In fact, in the 50 years since the Wyoming studies, dozens of strep throat trials have failed to document a single case of RF in the placebo arms. The most recent CDC data suggests the incidence of RF to be 0.1 per 100000. Therefore, in 2008 we’d have to treat over one-million strep throat patients to prevent one RF. One-million antibiotic prescriptions for strep throat will result in 24,000 potentially fatal allergic reactions, 100,000 cases of diarrhea and drug rash. To prevent one case of rheumatic heart disease, multiple these numbers by three (NNT to prevent one case of rheumatic heart disease = 3,000,000).

Using antibiotics for strep pharyngitis to prevent non-suppurative or supporative complications ought to be weighed against the potential to cause harm.
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# MDDr Sourbutt 2009-03-11 21:15
Until tort reform is addressed and dealt with in this country I'm afraid we will all have to continue prescribing antibiotics for streptoccocal pharyngitis... the scientific evidence be damned!
Greg Henry wearing his best Brooks Brothers suit and despite his acerbic quips and witty banter/repartee with the plantiff attorney would be toast as a med- mal defense expert in any court I know of with a bad outcome case...
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# We Have Never Been Diagnosed with Strep ThroatDennis 2009-03-13 01:18
I have 3 children. They are 20 yo, 17 yo, and 14 yo. My children, spouse and I have never been diagnosed with strep. Perhaps it is because I have never tested them for strep. We are all still alive today and doing fine. My experience is 99 times out of 100 when my kids get a sore throat, they get a cough and runny nose the next day. Obviously viral.
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# Thanks for the interestDH Newman 2009-03-13 20:23
Thanks everyone for your great thoughts about my article. Here are a few responses:

The questions about glomerulonephri tis and abscesses are excellent ones. If antibiotics could reduce the morbidity or mortality from these complications enough to outweigh the harm from antibiotic side effects then this would be reason to use them. However, no professional society or expert recommends using antibiotics for abscess prevention or kidney protection. This is because these complications are less common than antibiotic harms, including major harms like life-threatenin g allergic reactions. Only peritonsillar abscess is arguably more common. However: a) kids don't get PTA's, b) PTA's generally present primarily rather than after strep, making them impossible to prevent, and c) they're easily treated and almost never result in serious morbidity in the U.S. The NNT's are simply too high even for PTA to make it beneficial overall.

On medicolegal issues: this is another very legitimate concern. I would love to hear back from anyone who has direct knowledge of a lawsuit arising from non-treatment of strep throat. Please email me direct if so (dnewman@chpnet.org) as I'm trying to collect and verify these incidents. Through colleagues and friends whom I have surveyed I have so far found only two verifiable cases of malpractice suits related to sore throat prescriptions, and both were due to side effects of antibiotics (one fatal anaphylaxis and one deep abscess with multiple surgeries after IM pcn). In both cases the plaintiffs alleged the antibiotics were over-treatment and in both cases the patient had asked the emergency physician for antibiotics specifically. I am unaware of a malpractice case due to non-treatment of strep throat or sore throat, but would like to know about any that anyone else is aware of.

All of the above is the primary reason why most clinicians and experts who use antibiotics tend to invoke either rheumatic fever or else symptom relief as their intended targets for antibiotic therapy. Rheumatic fever is too rare to prevent without harming thousands (and likely causing a few cases of TEN or SJS or anaphylaxis) and pharyngitis symptoms are better managed by NSAIDs or steroids then antibiotics.

Thanks again everyone and please keep the discussion alive — this is exactly what we need.

DHN
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# ERDoc 2009-03-15 10:04
How can one truly know if a PTA presents primarily, rather than after strep? If a patient presents with a PTA or retropharyngeal abscess and it is being called a "primary abscess" the assumption must be they were seen prior to the abscess forming and had a negative throat culture. How else can you say with certainty it is a primary abscess?

A very quick google search of the AAP website states the following: (info for parents section)
If your child's strep test is positive, your pediatrician will prescribe an antibiotic to be taken by mouth or by injection. If your child is given the oral medication, it's very important that she take it for the full 10-day course, as prescribed, even if the symptoms get better or go away.

"If your child's strep throat is not treated with antibiotics or if she doesn't complete the treatment, the infection may worsen or spread to other parts of her body, causing more serious problems such as ear and sinus infections. If left untreated, a strep infection also can lead to rheumatic fever, a disease that affects the joints and the heart. However, rheumatic fever is rare in the United States and in children under five year old."

I haven't searched the official AAP guidelines for practitioners but this seems pretty straightforward to me. Send a kid with strep home with no abx and you are hanging yourself out to dry if there is any complication whatsoever.

It may be difficult to find any lawsuits due to non-treatment of strep because it's simply not the standard of care. Perhaps more studies need to be done, if they can pass the IRB.....
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# Amy Levine 2009-03-17 18:57
Different strains of GAS (group A strep) have different degrees of virulence. Most of the strains are fairly mild. But we still see a bad strain come through the community once in a while. In the past few weeks, at my institution we've admitted one child with acute rheumatic fever, one child with florid GAS sepsis, and one child with GAS osteomyelitis. Try to get any of us to withold antibiotics in a child with GAS infection!
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# recovering ER docMatt K. 2009-03-17 20:39
Great article that makes a great case for risks exceeding benefits. After reading it, I defintely feel more comfortable not Rx'ing Abx for pharyngitis that is suspected to be viral. However, not Rx'ing Abx after a ( ) Strep test seems like a surefire way to ruin your reputation w/ the public & consultants. Alot of re-education needs to take place to make this the new std.-of-care.
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# Needs of the one.Kevin Reed 2009-03-17 21:47
Very thought provoking article and discussion. Since the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely in the general population in 1994, it begs to question why they and other medical societies still endorse antibiotic use for "strep throats". It will be interesting to see what "bottom line" for antibiotics will emerge in the updated IDSA “Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis” expected later this year. Perhaps this issue will transform from the present belief that the needs of the one outweigh the needs of the many, to the more rationale "needs of the many outweigh the needs of the few...or the one. "
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# Guidelines on strep treatmentWhiteCoat 2009-03-22 21:53
Medscape recently published a short article about updated guidelines for treatment of strep throat here:
http://cme.medscape.com/viewarticle/589327
Many interesting tidbits of information.
I added some thoughts about the guidelines and about Dr. Newman's article on EP Monthly's blog here:
http://www.epmonthly.com/whitecoat/2009/03/antibiotics-more-harm-than-good-for-strep/
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# Antibiotics forStrep...Davi d Newman, M. D.william anderson 2009-03-24 23:32
Where is the C. V.? I hope that Doctor Newman is safely ensconced in some academic medical institution where he has no direct patient care respnsibilities . Imagine telling the mother of a febrile child with exudative tonsils and fever and tender nodes that antibiotics have are not indicated for what is probably "strep throat." And does he also eschew the use of antibiotcs for the middle of the night E. R. visit of the screaming child with the red eardrum?

Bill Anderson, M. D.
Laguna Beach, California
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# Thanks #2DH Newman 2009-03-28 05:35
All excellent commentary, well appreciated. A few clarifications and responses to aid in the analysis of this risk/benefit issue:

-By "PTA's generally present primarily", I mean that they aren't seen by a physician first. Unless they see a physician before the condition develops, it can't be prevented.

-Thanks for noting the AAP's stance on this. Important point. The AAP site and their guidelines are written, like most professional guidelines on strep throat, by a committee that hasn't closely examined this evidence. The Cochrane Collaboration review points out that the incidence of sinus and ear infections (and rheumatic fever) are all unchanged by antibiotics in trials from the past thirty years. No benefit. But it's quite true that the AAP continues to ignore the evidence and the Cochrane review by invoking these as reasons to treat. Feel free to drop them a line urging them to reconsider.

-I would urge anyone who has seen disseminated GAS infections to check with the patient about the course of their illness. You'll note that they almost never have a preceding pharyngitis, as hematogenous GAS spread from pharyngitis is reportably rare, and therefore not considered, even by any professional societies, to be a reason for antibiotic treatment of strep throat.

-If anyone has recently seen a rheumatic fever case please take pics and post them somewhere for us. With a few hundred cases each year in the U.S., most docs will now go a career without seeing one, and we should learn how to recognize it. Also note that rheumatic fever case series' and reviews demonstrate that the majority (about 70-80%) of cases are either not preceded by any throat symptoms, or else had a minor sore throat that didn't prompt medical attention. This makes them, like most PTA's, unpreventable.

-As for the red ear drum, you're right: I treat with proper analgesia. But antibiotics are generally not indicated, so I don't treat with antibiotics. Some patients are insistent, no doubt about it. But studies have shown that communication and empathy, rather than antibiotics, are what patients desire most. In my own clinical practice (full time) this means that antibiotic prescriptions are exceedingly rare for URI's such as otitis and pharyngitis.

-Finally, consider that life-threatenin g anaphylaxis from antibiotics is now far (about 4-5x) more likely to occur than is rheumatic fever, even in untreated strep. In addition diarrhea, rashes, and yeast infections can be expected, in aggregate, to occur about 25-30x more often than a PTA. These may be stats worth sharing with your patients when you discuss the risks and benefits of antibiotics.

Thanks again for weighing in everyone.

DHN
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# Robert Centor, MD 2009-04-06 18:20
While I understand this nihilistic position, I disagree strongly. We have at least 4 reasons to treat strep throat. First, we do decrease the incidence of acute rheumatic fever. If we became antibiotic nihilists we would be at risk for incurring a resurgence of ARF. Antibiotics probably do not prevent glomerulonephri tis - but we cannot be certain. Second, we do decrease the risk of suppurative complications. Given the morbidity of suppurative complications, one should try to decrease the incidence. Third, antibiotics for patients having significant symptoms do decrease symptom duration for as much as 2 days (Zwart, BMJ 2000). I would not that this benefit occurs with adolescents and young adults not preadolescents. In that study patients have very significant disease (by symptom and physical exam score). Finally, treating an index patient decreases the risk of spread to household contacts.

The other problem with this viewpoint is that we ignore Fusobacterium necrophorum and subsequent Lemierre's disease. I worry that a no antibiotic strategy would encourage physicians to care for sore throat patients in a cavalier fashion.

I disagree with the estimates of life-threatenin g anaphylaxis - especially when oral antibiotics are used.
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# Strep antibioticsjeflet 2009-04-06 20:01
Two questions,
Are we talking about proven strep throats, or do the numbers include all pharyngitis, which is likely to be viral?

Is it possible that antibiotics are reducing the pharyngeal bacterial count and thus the infectivity of patients, and therefore breaking the community cycle of infection spreading and thus treating one child effectively is preventing infection in 20 others. Maybe this accounts for some of the decrease in the prevalence of rheumatic fever?
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# InternistBohdan A Oryshkevich MD MPH 2009-04-10 02:51
I worked in an inner city FQHC where strep was common. In fact, a request for a throat culture was probably the single most common chief complaint. It was the transparent reason for going to the doctor often for other reasons.

The incidence of acute rheumatic fever falls precipitously in the late to mid teens. There are no more than a handful of ARF cases per year in those over 20. One would have to differentiate between children and adults in any kind of recommendation for not treating strep throat.

We also saw a fair amount of peri-tonsillar abscesses. I do not remember seeing one because of neglected strep.

In PSGNephritis one has to differentiate between sporadic and epidemic cases.

The request for a throat culture was so common that I immediately recall the following conditions being missed because the doctor simply fulfilled the patient request for a TC and did nothing else: pre-eclampsia, pneumonia, peri-tonsillar abscess.

I had patients with SVT, diarrhea, and pregnancy come in and ask for a throat culture. The administration was terrified of having patients requesting a throat culture and not getting it. This is not a well educated population.

I was considered an outlier in not fulfiling these requests when they bordered on the absurd.

But I would think that we would nee much more evidence before we could recommend that we should not treat strep in children, adolescents, or late teenagers. There must be or most probably is some relationship between our antibiotic treatment and the fall in ARF.

I would add that in thirteen years there, there was one person who might have had ARFever. There was one woman who had a brother and a child with ARF by history and she stated that in neither case was there antecedent pharyngitis.

There must a genetic susceptibility to strep causing ARF.
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# When did so many doctors loose their ....PedsERDoc 2009-06-22 01:25
What happened to doing what is best for the patient? I have been studying this very topic for years. There is NO doubt that prescribing antibiotics for routine pharyngitis that is strep positive is WORSE for your patient than doing nothing. What happened to taking care of your patient instead of caring for your own behind. It is rather pathetic that so much of what doctors are doing these days it out of fear. Stand tall, stay up to date, and practice in a way that is evidence supported - not based on our extrapolated quackery from the past.
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# MAXIDEX DEXAMETHASONE WARNINGWEL 2009-08-28 21:14
I had eye surgery and in the post-op pack was MAXIDEX(dexamet hasone) drops by LCON LABS.

two days later I was BLIND

Use Google and enter EPOCRATES MAXXIDEX REACTION to verify

Or call 800-757-9195
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# A lot of ResistanceSam 2009-11-28 01:02
The evidence seems clear that ABX are probably unnecessary, however, I've found it difficult to NOT give ABX to parents who come in requesting it. There's definitely a customer service aspect to medicine.
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# School Nurse at K-8th Grade facility, 450 students about 50 staffMonya McCarty 2010-01-24 03:31
I find myself at this site trying to understand what's going on at my school this '09-'10 fall/winter.
Out of a pop. of 500, I've seen 62 strep tests in 10 weeks. I believe the number is higher as not all MD's test, just dispense antibiotic. What baffles me is the various presentations, sometimes classic with fever but often the student looks viral with choriza and fever less than 99.5. My other confusion is how best to manage the volume I'm seeing and calm parents and staff. My own, very experienced and antibiotic-relu ctant pediatrician maintains Dr. Newman's position, but almost every other source advocates it. We're trying to clean and emphasize hygiene but you know kids in a school setting - grubby. How long to exclude non-abx students? Do the different strains of strep account for the varying presentations?
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# B ob Athanasiou 2010-03-08 18:46
the CDC web site says the following:
"Antibiotics are needed if a healthcare provider diagnoses you or your child with strep throat, which is caused by bacteria. Strep throat cannot be diagnosed by looking in the throat – a lab test must also be done. Antibiotics are prescribed for strep throat for the purpose of preventing rheumatic fever. If the test result shows strep throat, the infected patient should stay home from work, school, or day care until 24 hours after starting an antibiotic"


Kind of leaves you hanging out there doesn'it. I've been working at an FQHC and trying to save patients money by using hte Centor criteria and avoiding the use of rapid Strep Tests. Damned if you do, damned if you don't...
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# no culture testing if negative Rapid Strep TestsB ob Athanasiou 2010-03-08 18:57
Despite what the CDC says above, when it ocmes to adults, the web site advice to clinicians is as follows:
"Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis, nor for the confirmation of negative rapid antigen tests. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when pathogens such as gonococcus are being considered"

The story is different for pediatric patients:

Clinical findings alone do not
adequately distinguish Strep vs.
Non-Strep pharyngitis. 3
BUT, prominent rhinorrhea, cough, hoarseness,
conjuntivitis, or diarrhea suggest a VIRAL
etiology. 4
n Antigen tests (rapid Strep kits) or
culture should be positive before
beginning antibiotic treatment.
Experts suggest confirming negative results
on antigen tests with culture.5

the reference to experts is the AAP statement.
At least is seems we can treat adults rationoaly but not children.
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# Thanks for this great discussion...Serenity Kimball 2011-06-30 21:10
So I've been searching the web for the last couple of hours trying to decide what to do about my own sore throat. The day before yesterday I woke up with a sore throat. That afternoon I had a temp of 103 with chills and body aches and a bit of a headache. Now my temp is down to 101 but my throat is still very red and inflamed, some white patches on the tonsils, swollen and tender nodes in the neck. I don't have any other symptoms (cough, runny nose, etc). I really don't want to take antibiotics. I am breastfeeding and don't want to increase my chances of getting thrush (which I've had before and is no fun) and I also don't want to mess with the beneficial bacteria that colonize the gut. (I get the impression that most of you are medical professionals and it is disconcerting that none of you have mentioned this as one of the downsides of antibiotic treatment.)I have managed to avoid antibiotics for over 15 years but I thought if this was possibly strep that it would be irresponsible not to take them because of the fear of rheumatic fever. After reading this discussion would most of you agree that as a 35 year old female it is perfectly reasonable to not take antibiotics for this? I'd also like to know at what point should I seek treatment if I still have a fever or swollen tonsils etc. If my fever goes back up is that cause for concern? Is there a time frame that it usually takes to resolve itself? It is refreshing to hear different doctors debating these issues and knowing that treatment procedures are variable and not fixed in stone.
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# Link to this articleCarolyn Thomas 2011-11-04 08:45
Just a heads up, Dr. Newman, that I have quoted some of your comments here (with links back here, of course!) in my article called "When Patients Demand Treatments That Don't Work" on the blog, The Ethical Nag: Marketing Ethics For The Easily Swayed: http://ethicalnag.org/2011/10/30/patients-demand-treatment-dont-work/

And today, this article was also picked up as a guest post on The Prepared Patient Forum at:
http://blog.preparedpatientforum.org/blog/2011/11/guest-blog-when-patients-demand-treatments-that-wont-work/

Thanks a lot,

Cheers,
Carolyn Thomas
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# because i said so, that's why...Jennie 2011-11-11 15:37
I was recently diagnosed with a positive rapid strep test for the first time in my life at 41. I am very healthy female. While the pain in my throat was severe, I am allergic to Pen/Sulfa/NSAID S so my treatment plan was Levaquin and Tramadol. I took one dose of Levaquin and after a very uncomfortable night full of anxiety and insomnia, I started doing my research. As I suspected, the treatment of Strep Throat with mandatory antibiotics (or you'll die!) is a lot like the routine pulling of wisdom teeth and the routine penile circumcision of most little boys born in america. "because i said so, that's why"...let's not discuss the real medical need for such. thanks for your research and the lively discussion.
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# Rheumatic Fever Sydenham's ChoreaPJ 2013-02-19 16:25
My 5 year old daughter had a persistent cough and was not given a strep test in Jan. 2011 by the pediatrician. It is Feb. of 2013 and she is still recovering. She also got a rash on her entire body. She relapsed because the antibiotic wasn't strong enough in Sept of 2012. Please continue to strep test children when they have any sign of strep. I read that there are about 120 types of strep and 12 of them can cause Rheumatic Fever.
written by her mom
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