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.
wow…provocative…but will it really make a difference?
For what its worth. Not all sorethroat need antibotics but in one weekend we had 2 cases of rapidly progressive h.flu resulting in urgent intubation and eventual traches. Both patients were seen in an urgent cares center and sent out the day before without antibiotics.
My pet peeve is overuse of abx…
I have informed my husband and kids over the past several years that they are no longer eligible for abx since they have never completed an entire course….
They just don’t listen…
(you would think, since they all suffered through my nursing education, that they’d have a little respect for my nursing wisdom)…
getting people to accept that strep throat does not need antibiotics will be a huge uphill battle.
i’ll have to look at your data for RHD prevention and make my own assessment of it, thanks for the link
I had strep as a teen. I was pretty damn sick. I was in bed for a couple of days before my Mom sent me to the doctor. I don’t like the idea of people getting sick for a day and demanding an antibodic. But sometimes you just can’t fight it. I ended up with a huge rash. My mom thought it was from the antibodics or eating KIWI fruit. But seriously, as adult, I am pretty damn sure it was scarlet fever.
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As a former microbiologist, nursing student and the daughter of a man who had rheumatic fever as a child, I’m very interested in the Medscape article you reference. However, I don’t have a pw for Medscape. Any chance you can give me the journal info so I can look it up through my school’s website?
I am not in the medical profession, and while I am sure that there might be some rationale for the argument, I wouldn’t chance not taking antibiotics for strep–EVER. Several years ago my friend died from heart failure, the direct result of an untreated strep infection. Then, last spring, my sister went into toxic shock/sepsis from a neglected strep throat. She nearly died. Multiple organs failing…it was awful. She was in intensive care for a week. With the increase of invasive group A strep infections these days, including the flesh eating bacteria (necrotizing fasciitis), not taking antibiotics for strep would be like playing Russian roulette. Strep is nothing to mess around with folks.
Mimi is right…
Strep can be severe, some people get pin prick white dots and some get white spots the size of quarters… this is dangerous. IF penicillin hasn’t show resistance… then whats the harm in going to the docs and being safer than sorrier.
LOLOL
My son is on the Austistic spectrum and has a very negative reaction to antibiotics – he is allergic to some antibiotics but even for those that he is not, his GI tract can’t take it. He had several bouts of strep last year and we are trying to avoid it this year – any advice on steps we can take to prevent him from getting strep/strengthen his immune system? (He already is on vitamin supplements per his nutritionist’s recommendation)
Thanks
make sure you get him a tosillectomy that will reduce the recurrance of strep throat
I had strep throat, probably as bad as it gets. My throat was so swollen it looked like I didn’t have a neck. I cleared it up within 2 days, before I knew my swab tested positive. I took high doses of Vitamin C, probiotics, and Homeopathics given to me by my Naturopathic Doctor. I believe antibotics are not always necessary for strep throat, although, I was most certainly begging for them. I believe good health and a strong immune system is vital to the recovery from this infection.
working in the medical world I can definitely understand the misuse of antibiotics. but….on the other hand if we are talking about undue suffering 1 or 2 times a year then why is this a discussion? pain is suppose to be the 5th vital sign!! if u have ever had strep then u can relate. i have a son who contracts strep about 2 times a year. every time …(i can even smell the infxn at this point)we head to the doc. they culture it, wait for the full report and eventually treat..now it usually takes about 4-7 days for the full report to reach doc and then me. during that time my child has suffered with pain, missed school, lost weight, and increased possibility for scarlet fever!!! are these reasons not enough to treat???
Number need to treat to prevent rheumatic heart disease 300,000 (i.e., 300,000 patients must be given antibiotics before one case of RH is possibly prevented). BTW – no cases of RH have been demonstrated in the control arm of any RH study in the US performed in the last 40 years.
Amount of time antibiotics reduce symptoms by (on average) ~8 hours
Number of prescriptions needed before a significant reaction to antibiotics is produced (i.e., life-threatening – SJS, anaphylaxis, or C-diff) ~ 7,000 (i.e., for every 7,000 patients given antibiotics, one will have a serious reaction)
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.
Still want the Rx?
I feel like all the info is so contradictory out there. I was recently diagnosed with Strep c it was a random test I went to doc because I keep having this odd feeling like an allergy where my throat feels like its closing up except its not every day just like 2x a week. So doc calls and says you have strep c but your not contagious we don’t really need to treat it unless you want to. So I opt to treat it since online everywhere you read that if you don’t treat it can become a secondary infection. After my second pill of penicillin I got that feeling like my throat was closing up and I started to feel like feverish and just altogether wiped out. Now I dont know if I should take the pills or if I should stop. With all the contradictions especially within the medical community what am I supposed to do??
Not treating strep might sound like a good idea until it is your child that develops Rheumatic fever. This is what happened to us April 2009. My 7 year old daughter complained of a sore throat, I looked and didn’t see anything alarming, assumed it was just a cold. A month or two later she develops migratory joint pain that after a few days lands us in the ER. Long story short she had developed RF from the untreated strep (she was never bad enough that I seriously considered it might be strep & being a parent that doesn’t like my children on antibiotics I never took her to the doc – assumed it was just a cold). So now we’re on a long term antibiotic treatment & praying that if we have a reoccurance it will again affect only her joints and not her heart! Oh how I wish now that we would have treated (even unneccesarily) for that sore throat last year!!
Gina,
I’m very sorry that happened to your daughter. But your post assumes the antibiotics are benign. They are not. I my career, I’ve yet to see a case of RF (which you can get despite the antibiotics), but I’ve seen two severe (one fatal) cases of Stevens-Johnson Syndrome (both reactions to anti-strep abx) and too many allergic reactions to count. It is just as awful when one of these happens to someone’s child.
Our 4 year old son got sick, fever, sore throat. Gave ibuprofen and Tylenol for 5 days before taking him to doctor thinking it was just a cold. Found he had Strep Throat. I, the father, also caught it about 3 days of his symptoms.
So now we are both on Amoxicillin. Mine is 875mg twice per day, my son’s is twice a day , lesser dose. Horrible medicine, makes you nausea, headache, feeling weird.
But I’ve read so many stories about the possible after affects of Strep, i.e. RF and the previous poster Gina.
So is it worth not taking the medicine and developing some sort of heart condition later or just go ahead and finish the pills for 10 days and suffer the side affects……geez….
I have gotten strep throat like 13 times since I was in 6th grade. I am 24 now. So that is about once a year since 6th grade. I have had it twice in the last 3 months. (yes we are talking about getting my tonsils taken out) I know how much you suffer with this and I know the things that can happen if it goes untreated. These things might not always happen, but still the pain that strep causes is worth taking antibotics to get treated. Also, taking antibiotics allows you to do the right thing and not be contagious, just because you might not get RF doesn’t mean the person that you give strep to won’t.
The real problem is that people aren’t taking their medicine correctly, finishing the pills. THAT IS THE REAL ISSUE.