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Rapid test strep VS mono... or both?

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Today had a 13 year old girl with a 101 fever, sore throat, neg cough, bilat ear pain x 2 days.  No fatigue, ROS/FH/PMH neg.    Rapid Strep was negative.    Swollen, red tonsils with exudate, fever 101 in clinic, swollen ant cerv lymph nodes (non-tender), no apparent distress, ears good.    CENTOR says treat ABX, rapid Strep says viral/not GAS.  I gave ABX (Amox).

 

My question would anyone run a rapid Mono due to fever, sore throat, swollen lymp nodes?  What is everyone's opinion on it?    Do you run a mono for every neg strep but a higher CENTOR probability?  What is everyone's success with cephalosporins?   I started to think about it today more. If she gets a rash from Amox, is it a mono/amox rash or an allergy?  

 

Just want opinions?

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Did you consider F. necrophorum? https://en.wikipedia.org/wiki/Fusobacterium_necrophorum

If treating empirically with abx, why amox vs. plain Pen VK, especially since you're already aware of the rash potential?

Did you check for posterior cervical nodes?

How would a positive mono test change your treatment plan?  Can your patient afford it?

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I typically get throat culture in a situation like this with negative rapid strep. 

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I typically get throat culture in a situation like this with negative rapid strep. 

I never order a throat culture, because it costs the patient money and doesn't change my treatment plan--I give empiric PCN presuming F. necrophorum.  How does a positive culture affect your treatment plan?  How long does it take to get one back in your setting?

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Did you consider F. necrophorum? https://en.wikipedia.org/wiki/Fusobacterium_necrophorum

If treating empirically with abx, why amox vs. plain Pen VK, especially since you're already aware of the rash potential?

Did you check for posterior cervical nodes?

How would a positive mono test change your treatment plan?  Can your patient afford it?

 

I did not consider the F. necrophorum.  I have had great success with Amox, so I stick with it.  I will probably start with Pen VK, Epocrates puts it up to first line with Amox.  Is it covered by insurance?    No post cerv nodes.   A positive mono I would not have given ABX, I should of tested.  Patient brought up concerns with cost and if stuff was covered.  They had insurance, not sure how good it was.  I was going to test, but that gave me pause and I did not.  Rev ronin, some times it is good to talk it out, look for better ways. 

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Mono: fatigue usually a presenting complaint. Check spleen. 25-50% enlarged, or so "they" say.

Strep: Quindel RS tests have 70% sensitivity in peds and 90% PPV per NIH findings. Don't ask about adults (much worse).

Using oral PCN is a pain due to having to dose around meals (gastric acid), thus use amoxicillin.

Again, ONLY benefit of strep tx is reduction of sx and mild reduction of duration. When was last time ANYONE saw rheumatic fever, not scarlet fever? I give Rx and if not better in 7 days fill Rx.

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I never order a throat culture, because it costs the patient money and doesn't change my treatment plan--I give empiric PCN presuming F. necrophorum.  How does a positive culture affect your treatment plan?  How long does it take to get one back in your setting?

 

seems to be about 3 days average to get throat cultures back. Allows me to withhold ABX in a negative rapid strep without missing a true GAS infection, helping to prevent unnecessary ABX. Honestly haven't much considered F. necrophorum.  I believe the only indication for ABX treatment  in uncomplicated GAS pharyngitis is to prevent RF, as ABX do not significantly shorten the duration of illness. Most ppl with strep will be feeling  better in  7 - 10 days with or without treatment.  Sure RF is rare, but I have 2 patients on my panel with prosthetic valves presumed to be from GAS infection. 

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And their ages? Strep was an afterthought till the '48 faulty study out of Warren AFB on strep (the concern prior was diphtheria pharyngitis). RF was found to develop in 4% of untreated strep cases. No causation has ever been shown, only association. If association was correct with study, where are all the RHD pts younger than 60 y/o? No study has duplicated their findings per literature reviews. Tone not implied to be argumentative, only informative. There's a lot of money to be made seeing/treating tonsillitis/OM yet the fact is that these are self-limited conditions based on current day understanding. Things may prove to be different tomorrow.

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Your throat looks gnarly = you get abx.   I use Pen VK unless there is an allergy.  I do often test for mono as well (especially if the kid is in sports) if they don't have a history of prior infection but if both are negative and your throat looks gross, you still go home with abx.  

 

The doc I was working with the other day was actually reading an article about the incidence of patients having both mono AND strep - while I don't remember the exact number I remember we were both surprised by how high it was.  I had one just yesterday - tested positive for strep at PCP, comes to urgent care 4 days later to see me because she was getting worse even with abx - mono spot was positive.  

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I never order a throat culture, because it costs the patient money and doesn't change my treatment plan--I give empiric PCN presuming F. necrophorum.  How does a positive culture affect your treatment plan?  How long does it take to get one back in your setting?

Unsure how you defend that - sounds like a plaintiff attorney's dream......

 

Your throat looks gnarly = you get abx.   I use Pen VK unless there is an allergy.  I do often test for mono as well (especially if the kid is in sports) if they don't have a history of prior infection but if both are negative and your throat looks gross, you still go home with abx.  

 

The doc I was working with the other day was actually reading an article about the incidence of patients having both mono AND strep - while I don't remember the exact number I remember we were both surprised by how high it was.  I had one just yesterday - tested positive for strep at PCP, comes to urgent care 4 days later to see me because she was getting worse even with abx - mono spot was positive.  

 

 

wow - hold the horses - why on earth would you treat every case of tonsilitis with ABX - have you had any awareness of abx overuse, resistance, superbugs???

 

 

 

 

Come on folks lets atleast try to follow guidelines....

 

 

 

 

 

As for strep and mono - just had one the other day - Group G and Amox (3+ tonsils heading towards kissing) waiting for monospot - not needed as erupted in rash... mono and strep....

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"Unsure how you defend that - sounds like a plaintiff attorney's dream......"

One way is by saying "we don't have outside lab capability in our facility". If the patient is one of those who holds out for a couple of days (I know, most show within 30") and you get a culture, by the time the result is back the patient is about to resolve the pharyngitis. 7 days w/o improvement? Here's your abx prescription and fill it at that time. The patient that should get our interest peaked is the one sx for greater than 10 days who doesn't improve with the abx..

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Just to play devil's advocate - if the patient has +fever, +anterior cervical lymphadenopathy, +exudate, and (-)cough, why perform a rapid strep test at all? From a legal standpoint, if the patient were to develop a complication from the antibiotic, I think it would be harder to justify why the patient was prescribed the antibiotic in the presence of a negative rapid strep test vs. if you were to diagnose "exudative pharyngitis' and base the indication for antibiotics strictly off of clinical findings. 

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Mono: fatigue usually a presenting complaint. Check spleen. 25-50% enlarged, or so "they" say.

Strep: Quindel RS tests have 70% sensitivity in peds and 90% PPV per NIH findings. Don't ask about adults (much worse).

Using oral PCN is a pain due to having to dose around meals (gastric acid), thus use amoxicillin.

Again, ONLY benefit of strep tx is reduction of sx and mild reduction of duration. When was last time ANYONE saw rheumatic fever, not scarlet fever? I give Rx and if not better in 7 days fill Rx.

 

 

Agreed, I would expect to hear "fatigue" mentioned early in the history for mono to be at the top of my list to consider. Also, I'd expect the duration of symptoms to be measured in weeks, not days. 

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Your throat looks gnarly = you get abx.   I use Pen VK unless there is an allergy.  I do often test for mono as well (especially if the kid is in sports) if they don't have a history of prior infection but if both are negative and your throat looks gross, you still go home with abx.  

 

The doc I was working with the other day was actually reading an article about the incidence of patients having both mono AND strep - while I don't remember the exact number I remember we were both surprised by how high it was.  I had one just yesterday - tested positive for strep at PCP, comes to urgent care 4 days later to see me because she was getting worse even with abx - mono spot was positive.  

 

In the teenage/young adult group you can often get up to a 50% rate of concomitant infections.  I generally document an abd exam and if I'm concerned, get a CBC, mono, and AST/ALT.  I've seen more than my fair share, having worked both at a military college and on a number of bases with crowded barracks and young'ens running around.  Pus on the tonsils doesn't always mean bacterial tonsillitis, as you get it with some viruses (EBV and CMV mono do that).  I generally only use Amoxil for younger kids right now because there is an issue with getting Pen V elixir around here...anyone capable of swallowing pills gets Pen V from me unless allergic.  I'm trending more towards Keflex as a back up unless truly anaphylactic to Pen...and even then, I've only caused a couple of negative reactions.

 

This is all tongue in cheek of course, since in Canada, you don't need to pay for these tests right out of pocket...just out your taxes. 

 

SK

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If I believe that its strep, I go with VK. I use the center criteria a decent amount of the time. If I am what so ever suspicious of mono I go with Clinda to avoid the rash. Last month I had a 6 year old girl who was positive for Mono and strep and I went with Clinda. Some of my patients are ok with getting a one time dose of IM PCN due to it being one time which they prefer. I also use a fair amount of IM dexamethasone based on clinical presentation to help with their discomfort. 

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My experience comes from my own child. He had posterior cervical nodes and a temp of 101 and I just knew he had mono.

 

I tried not to be the clinician in his case. My husband took him in to our urgent care and they didn't really think it was mono. They tried to give them antibiotics and I said no. Our urgent cares are way too eager to give antibiotics. Our community really struggles with the idea of not giving into biotics for fear of patient retribution and bad scores from their corporate medicine managers. They did labs three days later and they were completely negative. A negative mono spot, a normal CBC and a normal CMP.

 

He was still completely miserable and the temp went up to 103 and the malaise hit like a truck. It took 10 days for his mono spot to convert to positive and by that time is AST and ALT were over 240 apiece. The on-call pediatrician ordered an Epstein-Barr virus titer and of course the IgM was sky high. I'm not sure how much that one cost me. It took another three weeks to get him back to normal.

 

No one ever considered strep. No one did a strep test. I knew from the very beginning that he had mono and his pediatrician finally told me that they should've gone with what I felt despite the test results. He actually trusts moms.

 

we do rapid strep in our clinic but we don't do mono spot. So it takes me 24 hours to get the mono spot back and I always order the CMP anyway because if the Mono was positive then I want to see the LFTs. A throat culture does take three days in our community and is often not very helpful. We get a lot of pressure from parents and schools to treat so that they can go back to school" not being contagious".

 

The overwhelming majority of sore throat in our clinic are from mouth breathing due to severe postnasal drainage from allergies or viral infections. For some reason people think that waking up with a sore throat that gets better if you have something to drink is an absolute crisis.

 

amoxicillin is the drug of choice in our community. I hardly ever see any prescriptions for plain old penicillin. Not even from dentists. They use erythromycin more than they use penicillin.

 

So, I have one immune kid to mono and thankfully nothing else happened. And his liver and spleen went back to normal.

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Unsure how you defend that - sounds like a plaintiff attorney's dream......

Easy: I treat empirically, since I cannot, even with a negative throat culture, rule out F. necrophorum, which can be as high as 25% of exudative sore throats in the young adult population.  If they don't look like they need abx, they get a symptomatic care discussion. Since F. necrophorum and Strep both respond to Pen VK, they get that to minimize the chance of mono rash.  Under no circumstances do I base abx tx decisions on a culture that comes back in a few days: they'll either be miserable for the duration, or fine, so if I can't decide same day whether abx are needed or not based on POS labs (e.g., urine dip), then I go empiric and clinical impression, such as Centor criteria.

 

On what basis would someone be suing me for giving PCN for a gnarly looking sore throat? Or, more specifically, what could I be missing that a strep culture would tell me in a few days that would change things?  That's a serious question--am I missing something in my cost/benefit analysis here? I'm all for minimizing antibiotic use when it makes sense to do so, but anything that's able to develop resistance to PCN has pretty much already done so, hasn't it?

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Funny thing with Monospots - depeding on the virus, the tests are often falsely negative in the first 2 weeks.  I prefer looking for atypical lymphs on the smear, since they're more likely to be seen first.  Of course, RC's kid is a bit of an anomoly :-D.  All silliness aside, mono is a disease of a wide spectrum - I've seen kids back at it in a week and others you'd think were going to die of some horrendous lymphoma, spleens almost to their ankles and such.  First bad case I saw was a combination mono with a huge PTA - not cool for the sick guy, pretty cool for me as an embryonic army medic.  If folks have kissing tonsils or really severe dysphagia, I'll give dex, otherwise I'll go with naproxen if they can eat and benzydamine gargles.  Being old enough to remember getting 5 or 10 megaunits of PenG in the arse, I don't tend to go there - hasn't made a come back here yet anyway.  If a tooth fairy (or anyone else for that matter) were to give me erythro for anything, I'd kick them in the junk and make them ingest it themselves...a good case of gut rot is good for the soul I believe.  I give Amoxil where it's a good first line, but, since S.pyogenes is pretty dumb and Amoxil causes rashes with many viral illnesses, if I remotely think a mono may be involved, I'll go with PenV...but since I'm The ABx Nazi, I'll still sometimes wait the 36-72hrs for the culture.

 

SK

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Strep throat threads are my #1 favorite thread on the forum.

 

One thing I always notice, though, is little mention of Strep pyo normal flora and the role it plays in a positive rapid strep in the absence of disease attributable to it.

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Ventana -

 

I am very aware of antibiotic resistance and among the clinicians at my urgent care, I am one of the LEAST likely to prescribe antibiotics.  However, given the sensitivity of the rapid strep test, the refusal of parents to send a culture and the lack of available testing for F. necrophorum.....   If your throat looks like junk, I prescribe abx.   Now if your throat is just a little red, you have cough/congestion - you get motrin 600 and magic mouthwash unless the strep comes back positive.

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If I believe that its strep, I go with VK. I use the center criteria a decent amount of the time. If I am what so ever suspicious of mono I go with Clinda to avoid the rash. Last month I had a 6 year old girl who was positive for Mono and strep and I went with Clinda. Some of my patients are ok with getting a one time dose of IM PCN due to it being one time which they prefer. I also use a fair amount of IM dexamethasone based on clinical presentation to help with their discomfort. 

 

 

Centor scale not as reliable as first thought based on follow up reviews but certainly not a bad starting point.  Just a suggestion, to avoid the diarrhea from clindamycin, unless you don't like the pt.; how about cephalexin?  BTW, we don't know the correct duration of tx. with PCN family products.  10 days?  7 days? 5 days?  We know the three day option didn't eradicate it as I recall (I think it was three days or maybe it was single dose tx..  Where's my Geritol?).

 

I agree about the 'roids since it has been shown to be most effective for sx. relief over NSAID/APAP and the antibiotic itself.

 

IM abx. not an option in my situation.  Welcome to Dodge City old school care where we give you whiskey at wound site and orally before removing the bullet.

 

Today's world:  Need new organs?  We can get them for you.  Basic sore throat?  Uh, we'll have to get back with you on what's considered correct.

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Centor scale not as reliable as first thought based on follow up reviews but certainly not a bad starting point.

Is anyone aware of a study that matches Centor criteria scoring to the total incidence of Strep pharyngitis + F. necrophorum pharyngitis?  The fact that F. necrophorum is a ridiculously hard bugger to culture seems to be confounding a number of evidence-based approaches...

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I've had enough strep swabs come back positive when symptoms are borderline that I've increased the number of folks I swab.  I have a strong preference for prescribing off the $4 (or free) lists given my patient populations, so I use amoxicillin.  Keflex is on the $4 list, but doesn't cover as well in my area.  Omnicef works well, but is pricey - so is clinda.

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Quindel brand RSS PPV is only 70%. Sensitivity is 59%. Results from NIH study and available online. For me, this is one of the first things I check with clinical tests that my facility uses. As boring as statistics can be, it is vital to understand the concepts of sensitivity, specificity, PPV, and NPV. For example, PPV of 70% means of 10 positive rapid tests, only 7 truly have the disease. Above sensitivity implies 100% culture reports result in only 59% positive RSS. For $25-30, I don't think one gets their money's worth.

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