DB1210 Posted March 20, 2014 Share Posted March 20, 2014 Hi! I am working on some research to see how and why rapid antigen tests have been adopted in primary care in the US versus the UK. As I understand most physicians will test patients for Strep A or flu if they suspect - rather than Rx antibiotics. In the UK they are not widely used by family doctors It would be great to hear some experiences of PA and how they use rapid tests? Views and opinions would be great? Also do family practices only use CLIA waived tests? If anyone has some time I would be happy to give them a call and discuss. Thanks Charles Link to comment Share on other sites More sharing options...
winterallsummer Posted March 20, 2014 Share Posted March 20, 2014 Seems pretty straightforward. Rapid strep test decreases over-use of unnecessary antibiotics. Even when the full 4 centor criteria are met, the positive predictive value is still relatively low. As far as flu, may justify use of the (controversial) tamiflu drug, or can help rule out other diagnoses. Centor criteria 2 or 3 out of 4 (ie moderate suspicion that someone has strep, or they "maybe have strep, maybe don't") prompts use of rapid strep, whereas high clinical suspicion it can be forgoed (straight to antibiotics) or low clinical suspicion just say it is very unlikely to be strep and no need to test. Flu testing, if pt presents with flu-like symptoms it can be used before ordering a chest xray (eg if positive less likely to need to order an x-ray unless still suspicious for pneumonia). I believe rapid strep is a useful test, can be used in peds, FM or ED. Useful and certainly cuts unnecessary abx use. The truth is even though it's a simple test many providers don't take the time to use it. But it should be used because it is simple, quick and leads to better care. I have less experience with the rapid flu test. Link to comment Share on other sites More sharing options...
Guest Paula Posted March 20, 2014 Share Posted March 20, 2014 ^^^^^ Agree with the above. Link to comment Share on other sites More sharing options...
Acebecker Posted March 20, 2014 Share Posted March 20, 2014 Should not be used as a substitute for clinical judgement, rather should be used in conjunction with/to strengthen the clinical picture. Sensitivity and specificity of these tests is not the greatest, but in conjunction with symptomatology can justify diagnoses. Link to comment Share on other sites More sharing options...
Guest Paula Posted March 20, 2014 Share Posted March 20, 2014 P.S. Other rapid tests we have used in FP that are Clia waived: Monospot, H. Pylori, RSV. We've let the RSV test go by the wayside as it was rarely ordered and the tests outdated. Loss of money to the clinic. Link to comment Share on other sites More sharing options...
DB1210 Posted March 20, 2014 Author Share Posted March 20, 2014 Hi Thanks for that. What do you think of Strep A and flu being done by pharmacists. I was talking to Prof Klepser who is running several pilots accross the USA and sees this as likely to go big? Charles Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 21, 2014 Share Posted March 21, 2014 Gotta question related to this topic. How many of you frankly, if given the opportunity, wouldn't even bother treating the strep if you knew the patient/parent wouldn't care? If you would treat it, what is the rationalization for same? Would it make a difference in your decision based upon the timeline of the illness (recent onset versus two or more days out)? I'm curious. Getting back on topic, most of those "across the pond" don't treat strep due to risk/benefit assessment of antibiotic therapy. Link to comment Share on other sites More sharing options...
DB1210 Posted March 21, 2014 Author Share Posted March 21, 2014 if anyone would like to do our questionnaire on rapid tests please contact me at (charles.rowlands@parioforma.com) We have some amazon vouchers as a small thank you for anyone who can spare some time. It takes about 40 minutes Link to comment Share on other sites More sharing options...
Acebecker Posted March 21, 2014 Share Posted March 21, 2014 GMOTM: I would. Not that this is anything you don't know, but I my justification is as follows: while the potential adverse events of strep are rare, they are still fairly extensive. Rheumatic heart disease is the big one. It is nearly unheard of at present because of the advent of ABx use in GAS patients. While not generally life-threatening, the procedures used to deal with the downstream consequences (e.g. valvuloplasty or valve replacement) bear more risk. Post-streptococcal glomerulonephritis is a second. While also not life-threatening, the dialysis often needed (and procedure to secure an adequate dialysis shunt) can be potentially damaging in the long term. And if memory serves, these patients are at life-long risk for renal insufficiency/CKD and outright renal failure. There are psychosocial consequences as well and these are more vastly felt by younger patients - the very patient population most likely to suffer the serious consequences of GAS infection. I can see how this would be a moot point, though. On the one hand you have the rare-but-potential SEs of GAS infection left untreated. On the other, the rare-but-potential SEs of ABx administration. I think in the end the cost is about the same to the medical community, but if you view every needle poke as an increased risk for serious infection, every hour spent in an ER or hospital bed receiving IV fluids because orals are intolerable as an increased chance for severe adverse events, and all of the lost days to illness because of the above potential side effects of GAS tonsillopharyngitis then treating it seems to make sense. I think a similar argument could be made for the treatment of otitis media. Link to comment Share on other sites More sharing options...
winterallsummer Posted March 21, 2014 Share Posted March 21, 2014 I agree, treat strep because complications, albeit rare, are serious. Also even if you only shorten the course by two days, if you have had strep then you know those two days are almost always worth it. ADRs to abx are always a risk but IMHO certainly justifiable if a strep dx is reliably made. As far as pharmacists doing the tests, I am all for pharms and value their input greatly, but they are not trained to be diagnosticians and how are they basing who to test? And if they get a (+) test then what, since they cannot write scripts? And say they get a (-) strep but miss a serious diagnosis and reassure the pt who actually has a malignant LN but goes home thinking "well it's not strep", or say they have a serious pharyngeal abscess, etc etc. Sure this is an extreme example that probably seriously underestimate's a pharm D's knowledge but these things need to be considered nevertheless. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 21, 2014 Share Posted March 21, 2014 I actually made a comment to a SP who was being groomed for the ED director role at a particular facility who I swear said that there were no renal complications. Also the same SP that said one couldn't use an MDI for bronchitis/cough (back when it was felt to be more therapeutic). Personally, I have no issues with treating it just based on Centor criteria but folks love tests so why not give them a test...as long as you're willing to explain about false negatives, etc. ("I've been sick for one hour and I know I have strep"). Frankly, generic cephalexin has been shown to be effective and you don't have to worry about PCN so much or the missed mono interaction with amoxicillin. I'd still like to hear others comments. I really enjoy these types of clinical discussions. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 21, 2014 Moderator Share Posted March 21, 2014 if memory serves, use of abx decreased risk for rheumatic fever but not post strep glomerulonephritis. no one mentioned my favorite rapid test, malaria antigen. very helpful when working up FUO in Haiti... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 21, 2014 Share Posted March 21, 2014 Has anyone ever actually seen a real live rheumatic fever case in a kid? Or an adult for that matter? If I have I sure as heck missed it. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 21, 2014 Moderator Share Posted March 21, 2014 Has anyone ever actually seen a real live rheumatic fever case in a kid? Or an adult for that matter? If I have I sure as heck missed it. nope. have seen pertusis, malaria, dengue, typhoid, and tetralogy of fallot (without surgery) in Haiti. Also trachoma ( chlamydial eye infection that can result in blindness). Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 21, 2014 Share Posted March 21, 2014 Haven't seen dengue to know it or trachoma to know it (love disclaimers). Took me forever to figure TOF in a peds cardio setting due to all the murmurs going every which way. Never saw the kid post-op. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 21, 2014 Moderator Share Posted March 21, 2014 Haven't seen dengue to know it or trachoma to know it (love disclaimers). Took me forever to figure TOF in a peds cardio setting due to all the murmurs going every which way. Never saw the kid post-op. older kids with TOF actually have a funny walk they use to increase their cardiac output with a squat every few steps. there is probably a youtube video of it out there somewhere, the 2 I saw were dx across the room by a doc I know who had seen the walk before. Link to comment Share on other sites More sharing options...
whoRyou Posted March 21, 2014 Share Posted March 21, 2014 wrong post Link to comment Share on other sites More sharing options...
DB1210 Posted March 21, 2014 Author Share Posted March 21, 2014 The role of pharmacists is likely to expand in the US - with regard to rapid tests. As I understand from the current pilots in some states local pharmacies have created a collaboration with local primary care clinics which enables them to dispense amoxicillin without the need for the patient to actually visit the doctor. other states it is more restrictive. The big pharmacy chains are very keen. If you are interested you can follow this link: www.pppmag.com/article/1143/June_2012/Rapid_%20Diagnostic_Testing_in_the_Outpatient_pharmacy/ Any one want to take our survey please see earlier post and email me - and we will give some Amazon vouchers for your time. Link to comment Share on other sites More sharing options...
Guest Paula Posted March 21, 2014 Share Posted March 21, 2014 DB1210: Who Are you? Link to comment Share on other sites More sharing options...
sk732 Posted April 9, 2014 Share Posted April 9, 2014 I regularly use my rapid strep kits - used to hate them, since I'd gotten alot of false negatives in the past, but the one I have now is really quite good. I generally use it to shut up neurotic parents and adult patients that automatically equate all sore throats with strep and want a magic pill to make their viral pharyngitis go away. I've seen/used the odd malarial test when I was in the military as well as monospot, but the rapid strep is the only one I use in the office. SK Link to comment Share on other sites More sharing options...
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