Doing rapid streps at home

[waky02]

Anybody out there doing rapid strep tests from your home (obviously during off hours)

I live in a small community and there is a demand for someone to provide rapid strep tests, and if positive to prescribe ABX.  approximately 10 per week.

 

Assuming I can get my supervising physician to agree, I imagine malpractice would still be an issue.

 

anyone with experience with this?

 

 

 

[CAAdmission]

Most of the rapid strep manufacturers "require" that you do a culture at the same time as the rapid strep to minimize the likelihood of a false negative. So if you follow the standard of care you are still stuck running down cultures.

[SocialMedicine]

I am not sure that is necessarily the standard in all settings. If a patient has a VERY likely viral pharyngitis and a rapid GAS is negative I will often discharge with instructions to f/u in 2 days if not improving. Obviously many of the rapid studies will fail to detect other bacteria outside of GAS.

 

I am confused by your proposal. Rather then patients scheduling an appt at your office you would rather they come to your home after hours for a rapid strep study/consultation if they suspect strep pharyngitis ? Does your triage nurse make sure it is appropriate in advance with screening questions? What if it is likely EBV mono, HSV stomatitis, influenza, or pharyngeal abscess  will you also carry equipment to assess them in your home ? Are you looking to charge cash for these visits at a high fee ? I fail to see the incentive here. 

[Guest Paula]

^^^^ I agree. Don't do it. You will get malingerers, drug seekers who need vicodin for their sore throat, and there is no place for doing rapid streps outside of a clinic setting.  I wouldn't even want to write a script for anything for anyone outside of the clinic environment. PAs will and do get in trouble for this type of practice. 

 

Docs don't.

[cbrsmurf]

Even if you truly have strep throat, you don't need to treat it most of the time.  RF is extremely rare.  I would only treat in the elderly, <2 y/o, or risk of airway obstruction/peritonsillar abscess.

 

NSAIDs, APAP, and/or prednisone for pain control.

[ATCLATEMTB]

Even if you truly have strep throat, you don't need to treat it most of the time.  RF is extremely rare.  I would only treat in the elderly, <2 y/o, or risk of airway obstruction/peritonsillar abscess.

 

NSAIDs, APAP, and/or prednisone for pain control.

 

 

Renal Failure from Post-Streptococcal Glomerulonephritis is by far not the only concern of untreated Strep....... the cardiac and neural complications are enough to inspire treatment.  

[waky02]

To elucidate

the concept would be to satisfy a neighborhood demand, on a all cash basis, and completely outside of a clinical environment.

 

From a medical perspective  a positive strep would equal a abx script, a negative strep = f/u with PCP

other diagnosis such as those raised above i.e EBV mono, HSV stomatitis, influenza, pharyngeal abscess would equal a trip to the ER or f/u with PCP in the morning

 

Thank you for your thoughts on the matter

[Simplify]

Even if you truly have strep throat, you don't need to treat it most of the time. RF is extremely rare. I would only treat in the elderly, <2 y/o, or risk of airway obstruction/peritonsillar abscess.

 

NSAIDs, APAP, and/or prednisone for pain control.

Say what?! Could you humor me and tell me what data you have to support not treating patients with strepthroat??

[LKPAC]

Even if you truly have strep throat, you don't need to treat it most of the time.  RF is extremely rare.  I would only treat in the elderly, <2 y/o, or risk of airway obstruction/peritonsillar abscess.

 

NSAIDs, APAP, and/or prednisone for pain control.

 really?  This is not the standard of care where I come from.  

[UpRegulated]

Say what?! Could you humor me and tell me what data you have to support not treating patients with strepthroat??

 

He's sort of right - theoretically.  Many times strep will resolve on it's own.  However, the rarity of RF and other sequelae are the result of consistent antibiotic use.  The standard of care is abx.

[SocialMedicine]

yes other strains of strep (Not group A) it is acceptable at times not to treat if patient has minimal and improving symptoms. Group A strep the recommendation is to always treat. And a dose of PCN sounds a lot safer than prednisone int he setting of infection. 

 

And sorry to have come off rude to the person asking question. Having had a private practice for 6 years , at least in the setting where I as, it did not sound worthwhile. 

[winterallsummer]

Don't forget there are purulent complications of strep. Also psgn is likely not prevented by abx tx and is auto immune in etiology as a strep complication. Plus treating likely does decrease length of dz. I have seen some podcasts saying treating strep is pointless but do not know anyone who would see a positive rapid strep or cx and not treat.

 

Also to the OP - are you aware they sell rapid strep to the public? People can buy these and if positive see you in your office. I personally wouldn't want contagious PTs lining up to come inside my house and can't imagine it being lucrative enough to be worth while. I mean no offense at all.

 

If you decide to do this, don't forget you need hippa compliant charts on all PTs.

[cbrsmurf]

Cochrane has an excellent review here:

http://www.thecochranelibrary.com/details/file/1239111/CD007470.html

 

Rheumatic fever is rare, and subsequently chronic rheumatic heard disease is even more rare (in the US).  In the US, the cost, detection, and treatment of GAS pharyngitis doesn't make too much sense.

[cinntsp]

Cochrane has an excellent review here:

http://www.thecochranelibrary.com/details/file/1239111/CD007470.html

 

Rheumatic fever is rare, and subsequently chronic rheumatic heard disease is even more rare (in the US).  In the US, the cost, detection, and treatment of GAS pharyngitis doesn't make too much sense.

 

Emrap had a great discussion on this. Essentially - one is at greater risk for a serious complication of abx treatment than for getting rheumatic fever and even greater for actually ending up with rheumatic heart dz.

 

[True Anomaly]

Thank you wutthechris for posting that- I was going to post something similar.

 

I trained at a place that didn't do rapid streps- we evaluated based on Centor criteria- obviously a 4/4 got antibiotics because it's the standard, 0/4 or 1/4 got supportive care.  2/4 or 3/4 is a call based on gestalt.

 

Let's also not forget the more rare but more serious sore throat etiology that has nothing to do with Group A Strep- Lemierre's Syndrome (please forgive the Wikipedia link): http://en.wikipedia.org/wiki/Lemierre's_syndrome

[REMPAC]

http://www.nejm.org/doi/full/10.1056/NEJMcpc1310001

[Simplify]

Emrap had a great discussion on this. Essentially - one is at greater risk for a serious complication of abx treatment than for getting rheumatic fever and even greater for actually ending up with rheumatic heart dz.

 

 

Thanks for sharing this.  I understand that rheumatic sequelae are pretty rare, but I am not fully convinced that you can write off a peritonsillar abscess as "no big deal, just put a knife in it."  I am sure others will weigh in.

[cbrsmurf]

There are certainly complications as everyone has described above from GAS pharyngitis, but one has to take into the account the epidemiology, benefit of NNT vs NNH, and the health status/toxicity of each individual patient (as well as the growing epidemic of abx resistance).   Lemierre's and RF and GN/kidney damage are rare, but I understand that given litiginous nature of medicine, it is tough to not treat.  Again, I think GAS pharyngitis is overtreated and current guidelines doesn't reflect current data. 

 

Oh and thanks for finding some references, I thought I was taking crazy pills for a moment

[db_pavnp]

Question.  Is one safer from litigation by prescribing an antibiotic with a 1/24,000 odds of ADR vs development of RF at 1/1.5mil?  I assume the answer must be yes.

[ventana]

for the simple ST - why bother in an otherwise healthy person

 

remember it is only GABHS that causes problems and there is literally thousands of other bacterial etiologies

 

As for renal issues - last time I looked the treatment of strep had ZERO effect on the course of post strep renal issues so this is not an issue

 

 

 

I think treatment is reasonable IF you are following the guidelines - problem is that to many times a rapid comes up negative, the cutlure is pending and a provider treats anyways......  WHAT?

 

 

I have heard it time and time again.....  and it is illogical at best and stupid at worst

 

RF, Endo, and most the other issues with strep throat take time to develop and you have a few days to get the culture results

 

Simply "trumping" the guidelines with your own decision should not b e done for the normal out patient sore throat.

 

 

There are times when this doe not apply, but this is not the "normal out patient sore throat" - ie PTA DDx, Uvula deviation, horrible throat, impending airway......  these all fall under a different treatment paradigm....

 

 

PSGN is not a reason to treat......

 

 

 

clarifying my position - if you test and a rapid strep comes back + you should treat - and can not think of a reason why you wouldn't in this case (why do a test if you are not going to treat). Yes it is the standard of care to treat a rapid + strep ST.  My comments above are about the people that get a rapid negative then still treat to make the patient happy.  (in what otherwise appears as a nontoxic appearing throat)

 

However - if you have someone with PTA on the DDx and single sided swelling, really sick, multiple comorbid, or one that you know you are going to treat anyways, why bother with the rapid as it is not going to change your treatment.

 

I once had an attending early in my career say "a throat that looks like that deserves treatment" and at first I thought that was BS - why not just treat based on the rapid - then I watched and learned over the next decade and sure enough that was a wise comment.  Those patients commonly don't get better, get worse, require further care, and in general treating early when the Ddx of throat infections is in the possible.  I am not talking  about the simple ST here......

[winterallsummer]

I think we can all agree psgn and perhaps even RF are unaffected by abx use and so rare it's outweighed by ADRs, respectively.

 

That being said, if nnt for peritonsillat abscess is 50 or even 100, and I do not know nnt for other supparative complications, but lets assume the overall nnt to prevent all and shorten disease duration by 12-24h (based on the above summary assuming it reflects most current data) is 40-50... That being said, irregardless of what you say on a forum, how many of you out there are honestly not giving abx to someone with rapid strep or cx proven strep??

 

I am not talking about 3 or even 4/4 centor criteria (which is still only about sixty percent specific). I am saying in your ER or office, rapid strep and/or cx is positive and clinical picture c/w strep, how many of you are actually not giving abx in your practice??? Until there is data strong enough to truly change standard of care, I am wondering if anyone of you all really would not write an rx in this scenario. I am not trying to judge but just curious if anyone is actually practicing this.

 

Also just sticking a knife in the abscess - give me a break. This can be a serious complication and require days of in pt care.

 

I'd be interested to see strong evidence backing nnh > nnt considering all complications of strep. Just saying since psgn is not altered by abx and that rf is rare doesn't cut it for me.

[cbrsmurf]

Personally, I would make an informed pt-clinician decision in a positive test. "The chances of complications from your strep throat are very low.  We can watch and wait and your body will fight off this infection >99.9% of the time without any problems, or we can give you some antibiotics that may or may not hasten your recovery and perhaps also reduce the chances of complications." or "I'm going to write this Rx out for you.  If you don't feel better after 3 days or get worse, get it filled out and give me a call."  If the pt wants abx in this case, I have no problems Rx'ing it.  There are bigger battles to fight

[cinntsp]

I'd be interested to see strong evidence backing nnh > nnt considering all complications of strep. Just saying since psgn is not altered by abx and that rf is rare doesn't cut it for me.

 

Have you read through the cochrane review?

[winterallsummer]

Here is the cochrane review summary. I may be wrong but I believe this was for sore throat whereas I am talking about rapid or cx proven strep. I am not advocating abx for non proven strep because most are viral. But I personally would not choose to not treat cx or rapid test proven strep. I am not saying others are wrong and maybe I am way off base. Just trying to have a discussion here because I've personally never seen someone not tx a cx proven strep in real life.

 

Background:

Sore throat is a common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it.

 

Objectives:

To assess the benefits of antibiotics for sore throat for patients in primary care settings.

 

Search strategy:

We searched CENTRAL 2013, Issue 6, MEDLINE (January 1966 to July week 1, 2013) and EMBASE (January 1990 to July 2013).

 

Selection criteria:

Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications.

 

Data collection and analysis:

Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. We contacted trial authors from three studies for additional information.

 

Main results:

We included 27 trials with 12,835 cases of sore throat. We did not identify any new trials in this 2013 update.

 

1. Symptoms

Throat soreness and fever were reduced by about half by using antibiotics. The greatest difference was seen at day three. The number needed to treat to benefit (NNTB) to prevent one sore throat at day three was less than six; at week one it was 21.

 

2. Non-suppurative complications

The trend was antibiotics protecting against acute glomerulonephritis but there were too few cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two-thirds within one month (risk ratio (RR) 0.27; 95% confidence interval (CI) 0.12 to 0.60).

 

3. Suppurative complications

Antibiotics reduced the incidence of acute otitis media within 14 days (RR 0.30; 95% CI 0.15 to 0.58); acute sinusitis within 14 days (RR 0.48; 95% CI 0.08 to 2.76); and quinsy within two months (RR 0.15; 95% CI 0.05 to 0.47) compared to those taking placebo.

 

4. Subgroup analyses of symptom reduction

Antibiotics were more effective against symptoms at day three (RR 0.58; 95% CI 0.48 to 0.71) if throat swabs were positive for Streptococcus, compared to RR 0.78; 95% CI 0.63 to 0.97 if negative. Similarly at week one the RR was 0.29 (95% CI 0.12 to 0.70) for positive and 0.73 (95% CI 0.50 to 1.07) for negative Streptococcus swabs.

 

Authors' conclusions:

Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to benefit. This NNTB may be lower in low-income countries. Antibiotics shorten the duration of symptoms by about 16 hours overall.

 

- See more at: http://summaries.cochrane.org/CD000023/ARI_antibiotics-for-people-with-sore-throats#sthash.UQG6CRFL.dpuf

[winterallsummer]

Also most current idsa still says tx strep.

 

Again I am personally talking about proven strep. I agree on a whole many or perhaps even most sore throats are not strep and in those cases abx are not useful.

 

http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/grpastrepidsa.pdf