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Doing rapid streps at home


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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

 

Thanks for providing that.  I found the IDSA's opinion interesting.  However, on further inspection of the guideline, they only reference a single study (surprisingly) on why GAS pharyngitis should be treated, and that was based on a global study (Which I can't read, as it is behind a paywall):

Carapetis JR, Steer AC, Mulholland EK, Weber M. The global
burden of group a streptococcal diseases. Lancet Infect Dis 2005;
5:685–94.
I'm guessing that it will reflect other data, if it even breaks it down, that complications from GAS pharyngitis is very rare in the US.  It would've been nice if they had addressed or re-evaluated the data, but that doesn't seem to be the case.
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Gordon's law of medical malpractice:

 

Expert witnesses are whores and will say whatever a lawyer wants them to say in court.  

 

You could easily find PAs and doctors willing to testify as "experts" that treating a + RST is malpractice.  Conversely, you can find an equal number of MDs and PAs willing to testify that NOT treating a + RST is malpractice.

 

 

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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

 

 

one has to remember that the reason the person came to the ER or office - was to complain of a ST and hope to get ABX....

 

better have pretty good reason (defensible) to not treat a + RS (or be prepared for the flood of complaints)

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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

 

What kind of a neighborhood do you live in?  I find this all very strange. 

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What kind of a neighborhood do you live in?  I find this all very strange. 

a small tight nit community, where there is just 1-2 degree of separation (using the 6 degrees of separation rule)

 

controversy above not withstanding, I think at this point the liability would be to great (I imagine that the malpractice would be cost prohibitive)

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Regardless of the clinical side, which has been covered well, you will have all the CLIA regulations that go with doing the lab test that would not be met if you are doing it from home, & you could be opening yourself up to litigation should someone decide to sue over it.  It may seem like a rapid strep test is the equivalent of a home pregnancy test, but it's not - some may need to be stored in a separate refridgerator that is constantly having temperature monitored & recorded, QA positive & negative controls must be done daily & with every new lot # prior to being used on a pt, & there may even be regulations that say the tests can only be performed in an OSHA approved setting (not sure about that one).

 

If it's for a house call type situation in which you take one from the clinic to the house call, you may be okay, because all the QA stuff should already be being done by clinic staff & you would be taking a test from the current lot # which should have already been tested for the day.  I would still check to make sure though.

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a small tight nit community, where there is just 1-2 degree of separation (using the 6 degrees of separation rule)

 

controversy above not withstanding, I think at this point the liability would be to great (I imagine that the malpractice would be cost prohibitive)

 

Ahhh....a jail gig?

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For all the posters who's responses fall under the "Whatchoo takin' 'bout WIllis?!" category, I invite you (implore you) to point your browser to SMART EM.  Dave Newman (author of 'Hippocrates Shadow') and Ashley Shreves very excellent EBM/EM blog and listen to his inaugural podcast from Sep 2010 - about why we worry way too much about the dreaded 'strep' and why we probably SHOULDN'T be treating the sh*t out of it like we have been for the last 40 years.  It's eye-opening, and if it doesn't change your practice - it should change the way you think about it (and hopefully THAT will someday change your practice).  It's well-worth your time - as are all of their podcasts.

 

http://www.smartem.org/podcasts/treatment-acute-pharyngitis

 

As cbrsmurf mentioned, sometimes I actually DO broach this choice - with the right kind of patient/parent (read: intelligent and no 'Drama Alert').  Sometimes it works, sometimes not.

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The warning at the end of the smartem podcast to ignore all of the NEJM clinical reviews was interesting.  I just had a drug rep give me a subscription to the NEJM clinical reviews.   Hmmmmm... will have to look at it a little more closer to see if he is right on that. 

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Attached is Newman's article in the March 2009 Emergency Physicians Monthly

 

Highlights:

 

"The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely."

 

"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."

"The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.
"

Antibiotics for Strep Do More Harm Than Good - EPMonthly 2009 - Newman.doc

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Gordon's law of medical malpractice:

 

Expert witnesses are whores and will say whatever a lawyer wants them to say in court.  

 

You could easily find PAs and doctors willing to testify as "experts" that treating a + RST is malpractice.  Conversely, you can find an equal number of MDs and PAs willing to testify that NOT treating a + RST is malpractice.

 

Gordon, as someone who has done some medical malpractice work, I disagree (surprise!) with your sweeping generalization that anyone who renders an opinion in a malpractice case is a whore. 

 

Are some expert witnesses in it solely for mercenary purposes and become known as plaintiffs expert witnesses or 'hired guns'?  Undoubtedly.  But I think that the majority of us who are engaged in a case do our level best to weigh all of the evidence as objectively as possible and determine to the best of our ability if the standard of care was met - regardless of 'side' (plaintiff vs defense). 

 

It should be obvious that it's not easy, and I and the few colleagues I know that have done it/are doing it agonize over the cases and struggle with all of the "there but for the grace go I" and 'Monday morning quarterback' biases and pressures.

 

Related to this 'expert witness = whore' detour but addressing the malpractice issue as it relates to this thread, if you've listened to the SMART EM podcast I linked to, Dave Newman still has the open invitation to be deposed or testify - for free (your attorney just has to pay the travel cost to get him to your venue) on any provider's behalf who is sued for not prescribing an antibiotic for pharyngitis, strep or otherwise.  It's at 54:50 on the podcast. 

 

I e-mailed him earlier this year to see if it still stood (as I was giving a lecture about pharyngitis at the VAPA Summer CME conference).  It did - and does.

 

 

As a parting thought, if - God forbid - you are ever named in a lawsuit, there will be a PA expert witness retained by your attorney being deposed (and possibly  testifying) on your behalf.  I daresay you won't think them too 'whorish' then, n'est-ce pas?   :-)

 
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