One of EP Monthly’s newest contributors, Dr. David Newman (of the “Hippocrates’ Shadow” fame), sets out a compelling case for why antibiotics may do more harm than good when treating strep throats. The results of the studies showing that antibiotics prevent rheumatic fever may surprise you.
This article is another example of the medical profession needing to examine treatments we consider as “standard of care” to determine whether the treatments are effective and whether the risk of the treatments outweighs the benefit of their use.
Also an interesting discussion in the comments section of the article on whether antibiotics prevent glomerulonephritis or retropharyngeal abscesses. Chris Carpenter, who is an EBM guru, responds to those questions as well.
ER Stories also has some discussion on the topic. Embarassed to say that TK scooped me on an article on my own site.
UPDATE MARCH 22, 2009
Medscape recently published a short article containing updated guidelines for management of streptococcal pharyngitis.
Important points to note include the following:
- Strep throat is self-limiting and resolves within a few days. [emphasis mine]
- The rationale for antibiotic treatment is prevention of suppurative infection, prevention of rheumatic fever, and reduction of communicability
- The antibiotic of choice is penicillin because no increase in resistance has been seen for the past 50 years
- Despite appropriate antibiotic treatment, chronic strep colonization is common. Children can be chronic “strep” carriers (i.e. strep present on culture without any signs of infection) for up to 1 year after infection, but there is generally no need to treat chronic carriers because they are thought to be at low risk of transmitting disease or developing invasive GABHS infections. [again, emphasis mine]
In summary, strep throat will go away on its own without antibiotic treatment and we only treat to reduce side effects that don’t occur that much to begin with.
In addition, if we swab family members of people who have strep “just to make sure” they don’t have it too, when we give antibiotics to those with positive results, we’re probably treating patients who have been colonized and won’t benefit from antibiotics anyway.
Finally, a question. The article notes that there has been no increase in the resistance of Group A strep to penicillin in 50 years. There is not a consensus on this issue. If we assume that strep has not become resistant to penicillin, could it be that the strep infections we are “treating” with penicillin would just have gone away anyway and that the penicillin is just a “placebo”?
Looks like a great opportunity for a randomized study.
Another recent Medscape article highlights the strep treatment/rheumatic fever reduction issue.