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Quick question about strep


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I found this on the IDSA website:

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5. Diagnostic studies for GAS pharyngitis are not indicated for children <3 years old because acute rheumatic fever is rare in children <3 years old and the incidence of streptococcal pharyngitis and the classic presentation of streptococcal pharyngitis are uncommon in this age group. Selected children <3 years old who have other risk factors, such as an older sibling with GAS infection, may be considered for testing (strong, moderate).

https://academic.oup.com/cid/article/55/10/e86/321183

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Let me make it clearer, me, who fails to accept the sky is falling fear of strep pyogenes. How many cases of rheumatic fever have been associated with untreated strep? Two. Both in 1961. Look it up. It is a self-limited disease. Benefit of treatment is same as treating primary influenza with Tamiflu.

 

I would love for someone to show me evidence otherwise. http://epmonthly.com/article/antibiotics-for-strep-do-more-harm-than-good/

 

Addendum: In the comments section Dr. Centor himself responds.

 

 

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Forgive me for not referencing the study, but even with strep positive cases, antibiotics shorten symptom duration by about 16 hours, on average.  That's it.  

 

And allegedly diminishes severity of symptoms. For an infectious process that kills the human population why are short courses of steroids advocated since that would just exacerbate the “terminal” nature of the illness? Said tongue-in-cheek.

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I always laugh when people come back after a day or so demanding a different antibiotic for their strep throat because it's still sore or the nodes are still swollen...because they expect everything to magically disappear with their Silver Bullet.  To which I respond - "The penicillin isn't there to make you feel better faster - we give it to allegedly/theoretically prevent other diseases.  You're still going to have a sore throat for a few days and you're still going to have nodes up for a week or 3."  I really want to say "This is a NO WHINING zone", but management, while allowing me to tell people things they need to hear, frown on me being overly rude and up front like that.

SK

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35 minutes ago, sk732 said:

I always laugh when people come back after a day or so demanding a different antibiotic for their strep throat because it's still sore or the nodes are still swollen...because they expect everything to magically disappear with their Silver Bullet.  To which I respond - "The penicillin isn't there to make you feel better faster - we give it to allegedly/theoretically prevent other diseases.  You're still going to have a sore throat for a few days and you're still going to have nodes up for a week or 3."  I really want to say "This is a NO WHINING zone", but management, while allowing me to tell people things they need to hear, frown on me being overly rude and up front like that.

SK

You probably aren't prescribing zpacks.  Those work better, and come blister packed.  

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9 hours ago, Cideous said:

Not sure I could of made it a career in medicine without my good old Z-pks.  It's like an old friend from college.  Kinda worthless and good for nothing now, but still has a few uses.  Mostly related to STD's.......haha.

Maybe we need to make some ZPack like placebos, call them Zen Packs or something - make a killing selling them to cold "sufferers".  You'd have your career track back on line.

 

36 minutes ago, GetMeOuttaThisMess said:

No. Spite gets you clindamycin.

 

True enough - seen people that start people on that for strep throat that aren't penicillin allergic.  Frig, I still use penicillin for my dental abscesses that come in...though if I was to be a real knobber, I'd put them on PenV/Flagyl, since having a tot for your toothache is kind of a common thing :-D, and that "I've got a bag of quarters in my mouth taste" really puts people off too.

SK

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C’mon folks! I’m poking you guys with a stick and allowing you to have a fruitful clinical discussion regarding whether we should give a hoot about strep pharyngitis? C’mon all you bright eyed and bushy tailed new grads. Are you going to take someone’s word for something just because they threw it out in a lecture? Whatever happened to thinking for yourself and drawing your own conclusions (poke, poke)?

 

Here’s an idea. I DARE any student to reference the above link with an attending and ask why we pucker so tightly at the thought of strep? “Hey, Dr. Attending! Sensitivity of a RST in the adult is only 59% which is less than Centor’s sensitivity and the PPV is only 70%?” First, know what these values mean, and second, get an A on your rotation for having the genitalia to ask them the question. I’d give an A just for thinking independently and being able to backup your opinion.

 

 

 

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I have to tell you I am fascinated by this because it flies in the face of what I was taught (in the late 1600s) and what I tell patients. I have kicked this upstairs and to my peds and ID folks for an opinion.

I suspect changing the mentality on this will be just as hard as stopping antibiotics for a virus has been.

For me this is a quantum shift in thinking on a subject I confront daily.

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I have to tell you I am fascinated by this because it flies in the face of what I was taught (in the late 1600s) and what I tell patients. I have kicked this upstairs and to my peds and ID folks for an opinion. I suspect changing the mentality on this will be just as hard as stopping antibiotics for a virus has been.

For me this is a quantum shift in thinking on a subject I confront daily.

 

 

As it was for me also when I first heard it years ago. I’m curious to see what the ID folks say. If Peds lose the fear of strep then they’re left with OM and immunizations (yes, they do more; I’m only kidding).

 

The comments section was quite divided as I attempted to point out. In 34 years I haven’t seen a known complication of untreated strep. That’s why there’s a recommendation out there for untreated pharyngitis w/o a focal source to receive a trial course of abx after 7 days. That’s why I give folks their door prize. There is no rush to treat. Somewhere there’s a statement that you have 17 days to initiate tx to prevent RF.

 

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 I have to say, when we see PSGN or rheumatic disease, it's (probably) largely because of the autoimmune response to the strep infection - even if it's treated, it still happens.  I've seen PSGN twice - both in treated people.  Haven't seen rheumatic fever, though seen after effects of it in older folks.  Funny thing about OM though - one of my lecturers in pediatrics was chief resident at The Hospital for Sick Children in Toronto back in the pre-penicllin days when they used to do mastoidectomies on a regular basis (the old poster was a kid in a mastoid dressing - it was the signature procedure of the place) due to repetitive under/untreated ear infections.  I can honestly say I've seen 3 cases of mastoiditis in kids/adults in the past 30 odd years as a medic and PA.  I know it flies in the face of things now, but the reason I was taught to treat OM (admittedly in the 1700's - Scott's a bit older than me, lol) was to prevent this...much like treating strep throat to prevent rheumatic fever or PSGN.  I guess it's going to have to take a proper RCT to prove/disprove complications of untreated strep infections...because it is still an automatic thing for me to write out the PenV Rx.  Using same script to prevent Lemierre's, since most labs need a specific order to culture for F.necrophorum, well that's a whole other kettle of fish I'm afraid - which is why I still use Centor scores and my brain (sometimes).

$0.02 CDN

SK

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I get what you're saying...that's why I'm saying maybe a real RCT should be done, not just based on how quickly it makes someone feel better (which in reality, is all anyone really seems to be interested in this world of "I can't afford to be sick"), but of apparent/alleged complication prevention that knee jerk antibiotic treatment seems to have eliminated.  I guess the only issue at hand is who is going to convince an ethics committee to allow something like this to happen when we believe that rheumatic fever and PSGN were all but eliminated thanks to us treating strep throat?  

SK

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18 hours ago, GetMeOuttaThisMess said:

Please don’t get me wrong. If I have an exudative tonsillitis (rarely see ex pharyngitis) or just really inflamed tonsils or throat I proactively treat. I’ve just always questioned why based the information noted above. Not because of strep per see but to cover for other critters and potential decreased symptoms.

 

The IDSA says not to proactively treat.  

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22 hours ago, sk732 said:

I get what you're saying...that's why I'm saying maybe a real RCT should be done, not just based on how quickly it makes someone feel better (which in reality, is all anyone really seems to be interested in this world of "I can't afford to be sick"), but of apparent/alleged complication prevention that knee jerk antibiotic treatment seems to have eliminated.  I guess the only issue at hand is who is going to convince an ethics committee to allow something like this to happen when we believe that rheumatic fever and PSGN were all but eliminated thanks to us treating strep throat?  

SK

I think we absolutely could convince them given the current evidence shows that rheumatic fever was decreasing in this country before antibiotics, still occurs in lower socioeconomic countries despite antibiotics, and PSGN is factually not prevented by antibiotics since it comes from the toxin released by the bacteria.

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2 hours ago, GetMeOuttaThisMess said:

 

That’s ok. IDSA isn’t the one seeing them. Give me a reliable, non-culture test that I can hang my hat on and then we can talk IDSA. BTW IDSA, what’s your opinion on Dr. Centor and his recommendation?

 

Agreed. If we are going to treat strep then we should also treat fusobacterium necrophorum, which clinically looks the same as strep but doesn’t show on culture because it requires a special agar, that COULD cause jugular thrombophlebitis.

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Agreed. If we are going to treat strep then we should also treat fusobacterium necrophorum, which clinically looks the same as strep but doesn’t show on culture because it requires a special agar, that COULD cause jugular thrombophlebitis.

Which is why I look at the throat and the age group...if it’s oogie looking, it usually gets something.


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