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.
There is so much that we don’t understand about the lives of microbes, it’s almost dangerous that we have access to antimicrobials. The antibiotics that work as cell-wall inhibitors (beta lactams)often select for the development of cell-wall deficient bacteria (so-called “L-forms”), which are increasingly recognized as causing human disease.
A quick example…antimicrobial treated strep infections are known to be related to the subsequent development of guttate psoriasis. It is also known that prolonged, high-dose antibiotic treatment is effective in treating chronic plaque psoriasis. This has been shown with both PCN and azithromycin. There is increasing evidence that sarcoidosis is treatable with antibiotics. It seems possible that many if not most of the medical conditions that we call “autoimmune,” especially anything with granuloma formation, are actually infectious diseases.
So I think that we are well-advised to be very judicious in our prescriptions for antibiotics until we are able to understand more about resistance and cell-wall deficient forms.
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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
tonsillectomy is an extremely bad idea and will most likely give him much more seriously problems.
“oil of oregano” and grapefruit seed extract are very powerful natural antibiotics. very awful tasting, but always helping my kids. but i don’t know if your son being so sensitive not maybe can not take those either.
Dear, thank you for your comment. people are so brain-washed these days with the Alopathic medicine, they think that antibiotics are needed in almost every case. I am having a strep throat now, and also taking an oregano oil capsules. It along gave me an immense relief. Yes, I am sick for the 6-th day now, still having a fever, but i do feel much better. One just has to believe in one’s own ability to come out of the disease. I am also breast-feeding, so can’t take antibiotics anyways.
Yana
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?
Dealing w/ a strep throat outbreak in a large family setting. One son has celiacs. Last thing we need to do is take down his immune system and strip his good bacteria. To those who say what’s the harm in giving antibiotics, you may have recurring problems from just that. 85% of your immune system is in your intestines! Antibiotics are a great tool to save a life, only to ne used in the most extreme of medical needs. Once or 2x in a lifetime would be reasonable of you diligently repopulate the gut, 1-2 times a year shows just how little people know about the damage antibiotics do while doing the good.
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.
I was diagnosed with colonized strep c recently. My seven year old son since he was younger will present with the strep rash and fever but does not test positive for strep A when swabbed. Could I have passed on my colonized strep c to him? Should he be put on antibiotics when he presents the rash and fever?
This seems ridiculous to me. I had symtoms of strep throat for three months that went untreated because my doctor didn’t want to overindulge in the use of antibiotics. I finally got penicillin, which took away most of my symptoms, but this was only after I started developing a rash and rapid increase in heart-beat when I walked. It will take many, many more studies to convince me that strep throat disappears on its own.
It is painful to have strep. Those who have suffered from it probably were hoping praying begging for a quick cure. Knowing that antibiotics would cure it, one with strep might be more than eager to take them despite the side effects/adverse effects. As a medical professional who sees and treats strep, I follow accepted guidelines. Until the guidelines change, i will continue the same practice. As once a patient who had strep….if I get it ever again….remembering that after only 1 dose I felt literally back to normal….I will be sure to be treated with an antibiotic.
I have strep right now, I can’t afford to get it checked out until my medical card arrives (been waiting awhile) its been about 3 and half days…it sucks…its painful…and with the internet its even a bit scary, thinking about all the stuff that could happe. If god wants me he will take me, if not, ill survive. Ill let you know. Its not a big deal, or is it? Haha…when its time its time.
Patrick, are you still alive and well? lol
I have strep now, haven’t seen an ms yet. I don’t take any pain relievers for headaches or anything. I do the natural stuff. Trying the oregano oil treatment and contemplating what to do if it doesn’t work. Because of ALL the antbx I’ve taken in my life time I’ve wound up with systemic candida. At this point taking the antbx would mess up all the treatment that I’ve done for the candida! I’m scared to take them and scared not to! I feel like it’s either my throat or my guts that will suffer no matter what I choose.
I ask the people who have had chronic strep, or strep ever – how do you live your life?
Are you constantly stressed-out?
Do you eat simple carbs, and dairy products?
I used to get strep ALL THE TIME when I was living the standard American lifestyle & eating the Standard American Diet (SAD).
Now that I have learned what nutrients my cells need to stay healthy on their own, well, I haven’t had a visit to the doctor’s office for strep in YEARS.
Shall we all do our own personal study? For the people that find themselves sick – what if you eliminated sugar and other processed, chemicalized, genetically modified “foods” for a while. How would your cells, muscles, skin, brain feel? Sick – with only healthy foods full of enzymes, minerals, vitamins, clean water, fiber, carbohydrates, proteins, fats, etc. going in?
Is it even possible for someone to be or feel sick if their diet & lifestyle are healthy and balanced???
“The Art of Healing; “Allowing Health,” Not “Fighting Disease”
With that in mind, is it any wonder that up to 80 percent of people actually end up dying in a hospital? And, if you read Dr. Gary Null‘s excellent piece “Death by Medicine” you will discover that adverse reactions from prescription drugs are responsible for nearly three-quarters of a million avoidable deaths EVERY YEAR in the United States alone.
We no longer die of old age. We die from inappropriate medical interventions that derail our bodies’ natural healing capacity.
All the more reason to seek out better, safer solutions to treat your health problems rather than relying on dangerous over-the-counter or prescription medications. Nearly the entire modern health care system is responsible for allowing countless unnecessary drugs to be prescribed, which leads directly to these prescription drug fatalities.
The fact is, prescription and over-the-counter drugs, designed to “fight disease,” kill more people every year than the combined deaths of all those who die from the use of every illegal drug in existence. So although a distinction is made between legal prescription drugs and illegal drugs used for recreational purposes there really isn‘t much difference is there?
What many people do not realize is that it is possible to maintain total health by avoiding unnecessary drugs and by gaining a comprehensive, clear and researched understanding of good nutrition and proper lifestyle choices, and by allowing healing, including the healing crisis, to take place without panicking.” http://articles.mercola.com/sites/articles/archive/2007/12/13/the-world-s-weirdest-deaths.aspx
Here’s another great article from Dr. Mercola: Disease Branding for the Sake of Drug Marketing.
http://articles.mercola.com/sites/articles/archive/2010/10/29/disease-branding-for-the-sake-of-drug-marketing.aspx
I have strep throat right now. I also had it about 10 years ago. When I went to the doctor for the first time (10 years ago) he prescribed some throat spray and no anti-biotics. My strep lasted about a week and went away on it’s own. This time I went to the doctor after feeling my lymphnodes swell and he prescibed some amoxicillan. This is only the third day of feeling symptoms and I’m feeling so much better. There were no side effects from the anti-biotics. It still hurts a little to swallow but is WAY better than last night. Last night I absolutely dreaded having to swallow and the pain was so bad I couldn’t sleep. I went into a urgent care clinic and the doctor prescribed antibiotics without a swab culture. I am very glad I went in when I did and these anti-biotics have helped alot! I think it’s important to get on the anti-biotics while in the early stages of strep throat to be more useful. I also picked up some airborne immune booster that seemed to help out as well. I’m hoping to get a good nights sleep and hopefully be able to eat tomorrow without any pain. I’m keeping my fingers crossed!
I have been getting strep at least once a year since I was a child and I’m 33 now. About five or or so years ago, I got it 7 times in one year alone. I’ve taken antibiotics about 85% of the time and the times I didn’t, it went away on it’s own. I don’t know that there’s any definitive answer as to whether taking them or not is right or wrong… as far as I can tell, it depends on the person. I just had it again a week ago and as usual I get the swelling, pain and white spots but that’s it… I never feel ‘sick’ or get a fever anymore (not since I was a teenager). I took Tylenol for the pain, as I usually do when it’s too painful, and it began feeling better within a few days and now it’s gone. I wish I had had my tonsils out when I was younger because after all the research I’ve done as far as having them out now, it seems that after 18 years of age, it’s an extremely painful surgery and just not worth it in my opinion.
At this point, it’s just something I’ve learned to live with and after having taken so many antibiotics, I’m just over it and have no plans on taking them again unless at some point it doesn’t go away on its own or gets worse. This is not a suggestion for anyone else, just a point of view from someone who has been dealing with strep for at least 20 years.
I wish everyone the best of luck with this because I know how frustrating it can be!
I am interested in alternate methods of treatment for strep throat since taking antibiotics often creates other medical problems like yeast infections.
Furthermore, since one type of antibiotic never seems to get rid of my strep, I’m usually given several different types of antibiotics until the dr. finds one that works. This means I’m in and out of the doctors office for six months or more trying to clear up one infection after another.
I’m sure I’m not the only one out there that has similar problems with antibiotics and I really wonder if taking them is even worth it.
What about strep that results in the rash (scarlet fever)? At that point, should antibiotics be used? Or is the rash not a big deal? I am a pharmacist, and we were taught that the rash was a progression, and the next consequence was likely to be rheumatic fever.
I recently got step throat…and I have had it many times…I just let my body treat itself. However, this time was very different. It was the worst pain I have ever had…and I was physically unable to get out of bed. Turns out I left it untreated too long. When I had s/s that were not normal for myself. I went to the ER…turns out I had a ruptured peritonsillar abscess. I don’t think I will ever mess around with my throat again…and right now I have another sore throat. I don’t want to be a hypochondriac…I just don’t ever want to be sick like that again. I ended up missing an entire 2 weeks of class and now have to wait a year to take the class over.
I just got strep for the first time, it was extremely painful and I immediately went to the dr. He gave me a prescription but said wait for results from lab. But if I were you I would start the antibiotics. So I tried waiting but couldn’t, as soon as I took this antibiotic I felt better. The lab phoned said yes you have strep come in for your prescription. I said I already have one, well that one is not strong enough but since you started finish. So I did but once finished I went back cause my throat was now not feeling right. Oh sorry that dr gave you an antibiotic that does not treat strep. Soo now I have not taken the new antibiotic and I am going to see if it clears up. I did have a rash when on the antibiotics was it scarlet fever… Don’ t know… Time to buy some more oil of oregeno.