This controversial article presents the case against treating strep pharyngitis with antibiotics. Antibiotics for Strep Do More Harm Than Good
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.
Here is my comment on this article:
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 glomerulonephritis – 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-threatening anaphylaxis – especially when oral antibiotics are used.
The author and I have planned to talk and have a good discussion of the controversy he has started. In his defense, many European countries recommend no treatment for strep throat. I disagree, but do so respectfully.
{ 6 comments… read them below or add one }
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. There are something like 200 cases of ARF per year in the USA. 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. As I mentioned above, I saw peri-tonsillar abscesses missed because a throat culture was done and the patient not examined.
In PSGNephritis one has to differentiate between sporadic and epidemic cases. May not the same be true for strep throat?
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. In my thinking the request for a throat culture was the equivalent of stating: Doctor I do not feel well.
I had patients with SVT, GERD, 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 fulfilling these requests when they bordered on the absurd.
But I would think that we would need 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.
This patient population is worthy of study and I would be willing to discuss it offline.
Bohdan A. Oryshkevich, MD, MPH
Excellent post, DB. Thank you for pointing out(again!) how a ‘simple’ problem (sore throat) is not so simple. (paging Mr. Merck-Medco)
One question: If an epidemic with a strep strain with a greater propensity to cause ARF got rolling, how long would it go on before it would be recognized and ordinary docs made aware? I remember (vaguely) the Utah outbreak in 1985-86 which occurred when I was in Arizona 20 miles south of the border with Utah, but I did not hear of this epidemic until 1987 when it was published (and I’d moved on).
I recognize the concerns, but have been impressed at the paucity of major complications with oral anti-strep antibiotics in over 25 years in family practice.
In the Pacific Islands, Rheumatic Fever is a VERY common sequelae of strep throat. As a matter of fact, Rheumatic fever is thought to even be caused by other skin infections with S. pyogenes as well. There might as well be an HLA/immunologic component to the whole thing if Europeans scoff at this, while practitioners in Hawaii see RF or RHD on a routine basis in the hospital.
Pharyngitis in general is usually caused by a virus, and no remedial treatment exists for this etiology.
However, if strep throat is identified, it should be treated with the appropriate antibiotic, as strep throat is contageous, and complications can develop with the strep throat patient if left untreated, although this is uncommon.
Sometimes, death is a very good thing- for a vicious multi-cellular organism.
There are a variety of different types of bacterial infections one can get from many different sources, yet some locations are more common than others. If bacteria are not beneficial for your health, as many bacteria are, they should die in order to restore your health.
Bacteria are a simple life form, yet are incredibly productive and efficient. As with other life forms, they exist to reproduce, and does so about every hour. Bacteria mutate, evolve, and adapt according to the host in which they exist.
To do this, it fully utilizes all available resources and energy to develop the protein that is essential for its survival in their host. Bacteria need exactly 7 genes to produce the essential ribosomes for their existence. Any more or less genes than 7, the bacteria is not maximizing its efficiency to survive and reproduce. Amazing.
Strep infections are caused by what are called gram positive bacteria, and they are the most common bacteria that infect other humans. . Group A strep infections can cause diseases such as strep throat and pneumonia. Also, staph bacterial infections are gram positive as well that potentially infect humans, and do so often.
Of all pathogenic, or disease-causing bacteria that exist, it is the MRSA, the methicillin resistant staff aureus bacteria, that are most concerning to health care providers in particular. This is because MRSA bacterial infections are the most difficult to cure when a patient suffers from their damage from being infected by these bacteria.
Another difficult situation is when a patient is infected by VRE, Vancomycin Resistant Enterococci, which is another type of gram positive bacteria that exist.
These MRSA and VRE bacteria are difficult to eradicate due to the fact that most antibiotics that are available to rid the patient of other bacterial infections, MRSA and VRE are resistant to the effectiveness of these antibiotics.
MRSA and VRE infected patients are quite challenging for the health care provider who is attempting to cure patients infected with these particular bacterial infections.
In many situations, pathogenic bacteria infect a patient already within a medical institution for another disease.
When this occurs, it is called a nosocomial infection.
Greater than 5 percent of nosocomial infections are determined to be MRSA infections, it has been reported. As a result, there are about 100,000 serious hospital infections, as well as about 20,000 deaths from MRSA infections annually.
Since there are several types of pathogenic bacteria that exist, a diagnostic test called a culture and sensitivity is usually performed at a clinical laboratory to assure the correct antibiotic is selected for treatment, as the bacteria are identified with this diagnostic method.
Typically, fluid from the area suspected of being infected is obtained from the patient suspected to have an infection and smeared on what is called a petrie dish.
And then these dishes are incubated for 2 to 3 days. Gram positive bacteria stain during this process a dark violet or blue. Gram negative bacteria would be pink in color, and are capable of harm as well to a human being.
When the culture is complete, technology that is available offers recommendations on the appropriate class or brand of antibiotic to treat the pathogenic bacteria present in another person- presuming the bacteria will not be resistant to the antibiotic recommended, as this happens on occasion.
Usually, classes of antibiotics that are used to treat gram positive strep infections that are not VRE or MRSA bacteria are cephalosporins, macrolides, or general penicillins. If the microbe that is causing the infection is resistant to the antibiotic from such classes that are administered to the infected patient, other options should be considered for anti-microbial therapy.
With two very powerful antibiotics in particular, which are methicillin and vancomycin, their frequent use in infected patients has resulted in VRE and MRSA bacteria that are now resistant to these antibiotics.
When a patient is infected with VRE or MRSA bacteria, other selections for antimicrobial therapy that provide more efficacy should be selected for a patient infected with these types of infections. Such brands and types of antibiotics for MRSA and VRE bacteria include Zyvox, which has both IV and oral dosage options, and an antibiotic called Cubicin.
However these antibiotics for antibiotic resistant bacteria are given usually due to infections that have progressed to a more serious nature within a patient infected in such a way, so a cure is not immediate when these antibiotics are selected for such patients.
Progressive medical conditions with such infected patients include sepsis, or blood infection, osteomyelitis, or bone infection, as well as pneumonia, which is a serious lung infection. A hospital stay is normally required with such patients infected with MRSA and VRE infections that cause such diseases.
This is because when the antibiotics that potentially cure the patient of these microbes are selected, they are usually given via IV administration, and are administered normally for several days, if not several weeks.
There are numerous classes and types of antibiotics available, yet bacterial resistance to most of these antibiotics, with the exception of the two mentioned earlier, constantly remain a serious concern for the health care provider, and the MRSA and VRE infected patient.
With MRSA at the top of the list of concerns for the health care providers, this infection continue to occur progressively, which amplifies the concerns of others.
Medical institutions should possibly consider quarantine for those patients at their locations that have been determined to be infected with the MRSA and VRE bacteria more often in the future.
http://www.cdc.gov/ncidod/dhqp/ar_mrsa_spotlight_2006.html
Dan Abshear
Thank you for the information. My 3 yo just tested "wildly" positive for strep and the dr sent me home with a scrip for him, and also for my 7 yo – who he NEVER EXAMINED, because the 7yo was the likely carrier, having had a sore throat and groin rash for about 4 days. 7 yo is back at school and feeling fine. It seems that his immune system did the job it was designed for. I am very hesitant to treat him for 10 days with antibiotics when he is clearly fine. Rheumatic Fever is extremely rare, from what I have read so far (we live in the US), and clearly the strep hasn't progressed to infected tonsils or adenoids or whatever since he has his appetite ,energy, and no discomfort. I will need to talk to my husband before a final decision, but I am leaning towards NOT treating my 7 yo with antibiotics. Where is the common sense in overtreating this child who is clearly healthy? That is the decision of this particular mom who tries to respect the medical profession while remembering that medicine, like all fields, changes and evolves (the dr who saw my kids today was MY pediatrician 30 years ago) so the precepts should not be followed without forethought.