I returned to the exam room with the results of the five minute rapid strep test on an elementary school boy whose mom had brought him in with a complaint of a very sore throat. “His strep test is negative Mrs. Thompson.”
“Well that’s a relief!”
My own thoughts about it were a little more mixed. Most of the non-strep throat infections are viral so you are left to just letting them run their course.
Pharyngitis is the medical term for infection or inflammation of the throat, generally causing the symptom of a sore throat. The problem is, someone with a bad sore throat is usually hoping for antibiotics to help them get better. In fact up to 70% of patients going to a doctor for a sore throat (and there are about 15 million people in the U.S. who see the doctor for a sore throat every year) receive antibiotics. At the same time, only about 20 to 30 percent of children and just 5 to 15 percent of adults with a sore throat have strep. Most of the rest have viral infections where antibiotics only contribute to side effects and more resistant infections, while providing no benefit..
So how do we sort out which infections are strep and which are probably viral? First there are other symptoms that help greatly. If there is a runny nose or cough with the sore throat it is almost certainly viral and not strep. A classic strep throat has fever and sore throat without runny nose and congestion, but often with nausea or headache. Also, age matters: strep is uncommon under 3 years of age, peaks between 4-7 years of age, and becomes less common in adults, though still showing up sporadically.
It has been shown repeatedly that even experienced doctors can’t reliably tell a strep pharyngitis from a viral one just by looking – there is too much cross-over in how they appear. So a rapid strep test really is needed for accurate diagnosis. These are up to 90-95% accurate and only take a few minutes. Recently it has been recommended that the old routine of double-checking a negative rapid strep test with a throat culture be abandoned as it adds cost without any measurable additional benefit.
Here is a question that is not as obvious as it first appears: why do we even want to treat strep throats with antibiotics. It surprises most people to hear that strep throat will usually clear up in a few days (about 7 days on average) even without antibiotics. The benefits of the antibiotic (usually penicillin unless a person is allergic to it) are that they:
- Slightly shorten the course of the infection (by 12-16 hours)
- Render the person non-infectious more rapidly (usually within 24 hours of starting the antibiotic)
- May minimally reduce complications such as abscesses of the tonsils or ear infections
- May possibly help prevent serious other complications of strep pharyngitis. But this is controversial as they have never been proved to prevent the kidney disease called post-strep glomerulonephritis. Likewise many argue that rheumatic fever (a serious complication permanently damaging the heart) doesn’t seem to be caused by the vast majority of the strains of strep currently occurring in the U.S.
So the benefits of antibiotics for treating strep throat are sketchier than they were once thought to be. And on the other side of the coin, about 10% of those treated with antibiotics get diarrhea, occasionally a serious type caused by C. difficile. Also 0.24% have a life-threatening allergic reaction. This means that out of 10 million patients treated with antibiotics, as many as 24,000 of them will have fatal or near-fatal allergic reactions.
Most sore throats get better without treatment, even including strep pharyngitis. So the decision to test and treat is a bit more complicated than it was once thought and deserves some individual thought on a case-by-case basis. As a little side note, that’s why the emergence of telemedicine (where patience are diagnosed and treated by phone) holds as much concern as promise. The tendency to misdiagnose illnesses and misuse prescriptions will only grow with this looser connection between patient and physician.
So who thought something as “simple” as a sore throat would take two articles just to summarize? But we haven’t even mentioned mono or the non-strep bacterial culprits that can be other serious causes of your sore throat. More on that next time.
This is part three of my question and answer session for the A Musing Maralee blog. Today I focus on antibiotic use and touch on overprescribing.
The original article can be found here. Andy Smith, MD wrote a related article on antibiotics found here.
When do we need antibiotics? Are they over prescribed? What should a parent do if they are concerned they are being unnecessarily prescribed antibiotics for their child?
Antibiotics are a powerful class of medications designed to kill off bacteria that have invaded the body. They are useful medications that can rapidly change the tide of a worsening infection. In the strictest sense, antibiotics are only used when the invading bacteria are not being sufficiently killed off by the body’s typical defense mechanisms thereby causing significant risk to the individual’s health.
This indication for using antibiotics is not as simple as some would like to think. For instance, ear infections in children may commonly be a bacterial infection that would dramatically improve with antibiotics. Different countries and cultures have different levels at which their healthcare community typically prescribes antibiotic help. In the United States, we have a low threshold for pain and suffering in our children and the standard for treatment is much sooner than the Northern European countries. The trade off is more antibiotic use but less complications from untreated infections.
The advice I give my patients is that I use antibiotics only when I feel they have a bacterial infection that their body cannot clear adequately enough on its own. Sometimes the evidence is very clear and sometimes it becomes a decision based on experience.
It’s important to note that there is a difference between an antibiotic and an antiviral medication. Antibiotics only attack bacteria and they do so largely by killing them. After a day or two of antibiotics there are fewer bacteria. The reduction is rather dramatic, honestly. Antiviral medications don’t work that way. They tend to stop the virus from replicating itself within the body. So if there are 100,000 copies of the virus present when the antiviral medication is started that number begins to stagnate. It only declines when the body begins to appropriately process and attack the infection. This is why antibiotics often have impressive effects in the first 48hrs while antivirals don’t.
I think antibiotics get over prescribed because physicians often assume the worst and patients often expect the best. Patients expect to heal more quickly than they really will and when that doesn’t happen they come in asking for something to make it better. Physicians are all too eager to help because as a group we want to “do something” to help our patients. If more antibiotics had annoying (but not harmful) side effects like turning your hair purple fewer people would over prescribe them. Even today a parent said to me about their child “But she can’t be sick, we’re going to be out of town in three days. Can’t you do something?” There is great pressure from many sides to over prescribe.
Parents who think they are being prescribed antibiotics unnecessarily should ask a few simple questions. Where, specifically, is the infection? Which bacteria is likely causing the infection? What do we gain by starting the antibiotic today? What do we risk by waiting to start the antibiotic? I would welcome any parent asking me these questions because they are the ones going through my mind each time I write out my prescription therapy. I need to be able to answer them well before deciding on the best course.
I was recently asked by Maralee Bradley, host of a great blog on adopting, parenting, and fostering children entitled A Musing Maralee, to answer some of her reader generated questions on fevers, the common cold, and influenza. I’ve had the privilege to do this before for her on a series of questions regarding vaccinations. It was a great experience for me and her audience asked some really fantastic questions. You can find those posts starting here. Years ago I had the opportunity to work with Maralee and her husband, Brian, in caring for their son. They have since moved, grown their household with more wonderful children, and continue to ask challenging questions of me.
The original post from her website is at Ask the Pediatrician: What should I know about fevers? I’ll repost the future Q&A’s as they get posted on her site.
What is a fever? When does it become a problem? How should I treat it?
We use body temperature as one of many tools to help understand how sick a person is. Any number on a thermometer, in and of itself, doesn’t provoke a certain diagnosis or a specific set of therapies. It only tells us information we then use to help decide why the person has an atypical body temperature and if anything needs to be done.
Core body temperatures fluctuate during the day and often reach their peak in the late afternoon. A healthy adult might reasonably be measured at 99-100°F between 4-5pm. Women attempting to time ovulation know their body temperatures change over the course of their menstrual cycle. It all has to do with what temperature is appropriate for the situation. One of the most critically ill children I ever cared for in the emergency room had a core body temperature of 94°F. He had a brain infection that was so severe he couldn’t even maintain a normal body temperature. While people are individual in what their body temperature normally runs this doesn’t change how we define a fever. People who really are sick enough to manifest a fever still get about 100.4°F.
So when do we worry about a rising body temperature? In infants we have to be more diligent because they lack many of the other signs and abilities we rely on in older children and adults to help point out the cause. An infant may be cranky or sleepy as a sign of their infection but lots of infants are occasionally extra fussy or take long naps. Unusual body temperatures help us tell the difference.
An infant less than 3 months old who develops a body temperature above 100.4°F should be evaluated by a physician in a matter of hours. They are at much higher risk of serious infections such as meningitis, urinary tract infections, and bacterial infections of the blood stream. As such, we must be all the more diligent to prove their fever isn’t of great concern. Hours matter in these situations so I often advise my patients who call in the middle of the night to seek emergency care if their infant has a fever. We must prove their health as the risk of fatal infection is so great.
In older children we move the ‘worry point’ to 102°F. When children under three years of age but older than three months develop a fever they often display more evidence of why the fever occurs and if we need to try and fix it. They can report ear pain or sore throat. They may be potty trained and then suddenly develop accidents because of an urinary tract infection. They stop eating and complain of belly pain with appendicitis. In these situations we are able to focus in on the cause of their over all problem of which fever is simply one manifestation. I typically recommend to parents that children under three years of age be evaluated by a physician as soon as possible. Often the next day in the office is just fine as long as there are no other red flag symptoms like shortness of breath or uncontrolled abdominal pain. Emergency care may still be necessary. When in doubt contact your physician for advice on what to do for your particular situation.
As to everyone older than three years of age, it all depends on the circumstances. For instance, we are currently in the mini-epidemic of our seasonal influenza infections. In this case, anyone with a fever and symptoms at all suggestive of influenza ought to be evaluated. Early diagnosis and therapy can make a big difference in influenza outcomes. However, most of the year when otherwise healthy people have a modest fever such as 101 F, I recommend a watchful waiting approach. Respiratory tract infections typically are self-cured in seven days or so and other more serious infections will manifest with other symptoms that will help guide our diagnosis and therapy options.
A word on how to take an accurate temperature. What we want to know is what the temperature inside the body is. Rectal temperatures are by far the most accurate and it is what I recommend to parents caring for infants. As children age, oral temperatures are very good as children can hold the thermometer under their tongue consistently. Remember not to eat or drink anything for about 5-10mins prior as that can alter the result. If your kids are asleep it doesn’t matter what their temperature is really. I certainly wouldn’t wake them up to test it. Under arm or axillary temperatures are pretty good also. Lots of people suggest adding a degree to those readings. I’ve never seen good data to show that should be done so I always just ask parents how they took the temperature.
Ear thermometers and forehead thermometers seem like a great idea but I’ve seen many inaccurate readings. I once saw a healthy, playful 5 year old boy with ear pain who was reported to have a temperature of 108°F! Turns out the ear they checked the temperature in was infected. His body didn’t have a fever but his ear sure did.
So once you’ve found a fever and appropriate therapy is underway, whether that’s letting to body do its thing or using proper medication to kill off an invading pathogen, the question becomes “Should we reduce the fever?” I think the answer really depends on the person. Many kids can run around and play normally with all manner of fevers while others of us tend to feel really run down. I would say treat a fever when, after you know what’s causing it, you need it to go away. I don’t know of any real advantage to leaving the fever just for the fever’s sake. Sure many bacteria grow best in normal body temperatures so changing that might slow them down. In my experience though the body is so fantastic at doing what it needs to do that the body temperature doesn’t play the deciding factor.
If you are a patient at Trinity then feel free to drop us an email or call us. Together we can decide how and when to treat a fever.
Let me tell you a little cautionary tale. Once upon a time (roughly twenty years ago) a strong new antibiotic came forth uniformed in a handy little green 6 pill, 5 day pack. Emblazoned across his uniform was the catchy swashbuckling name, Z-pak. For doctors, easy to write; for patients easy to take – dosed just once a day for five days. And man could he fight! All the common thugs feared him: bacterial sinusitis and bronchitis, skin infections, middle ear infections, strep throat, and even some of the more common community-acquired pneumonias – all of them seemed to melt back into the shadows at his presence.
And so the popularity of Z-pak grew. After a couple of years patients would often ask, not just for any old antibiotic, but for Z-pak by name: “Hey I’ve had a cough and congestion for a couple days. I really can’t afford to be sick. Could you prescribe Z-pak? It always clears me right up.”
But alas as the years went by something else started happening – Z-pak started to fail in his mission. I’d get a call back that the sinus infection was weakened but not gone – could they have another round of Z-pak? Over the course of the next 5 to 10 years those failures went from rare to somewhat common to rather predictable. Increasingly, Z-pak was losing the battle with the bad guys. After repeated battles with Z-pak, the “weak” bacteria were being killed off, but the strong, resistant ones were surviving and multiplying. Soon much of the community of bacteria was resistant to the once-mighty Z-pak. In short, he had become a victim of his own popularity. And we haven’t even mentioned the whole pack of viruses over whom Z-pak never held any power.
What can we learn from this little tale? First of all Z-pak is not alone. Any antibiotic that is frequently used tends to select out more and more resistant bacteria. And so, when an effective antibiotic is really needed, sometimes it’s hard to find one that still works. Indeed there are now some super-bugs out there showing resistance to nearly every available antibiotic.
So who needs antibiotics? Legions of sufferers of serious bacterial infections do. How can we maintain the effectiveness of antibiotics so that when we need them, they still work? There are several vital steps needed:
- Avoid treating viruses like the common cold with antibiotics. They are simply of no use at all in fighting viruses and they only add expense, side effects and resistance problems.
- Don’t be too quick to throw an antibiotic at every ear infection, sinusitis or bronchitis. Many of these are either viral (where the antibiotic is useless) or a mild enough bacterial infection where the body can fight it off without the antibiotic.
- When you really need an antibiotic, take all of it at full strength. Otherwise you may kill off only the weak susceptible bacteria while leaving the partially resistant ones to multiply and re-infect yourself and others.
- Get appropriate immunizations against common infections so that your own immune system can kill infections before they really take hold, thus reducing the need for antibiotic treatments.
Who needs antibiotics? We often do, and if we can get better at calling them out to fight
for us only at the right times, they’ll be there to help us when we really need them.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835