Rapid Strep Test not used at the clinic I work at - problem?

[cbrsmurf]

No monospot test either at one of the FP/UC places I work at (per MD's preference).

 

I am just wondering I should be pushing to get the rapid strep test (and monospot) at the clinic, cause I find myself Rx'ing more antibiotics for pharyngitis. I know that rheumatic fever is pretty rare in the US, but I don't know know if it's because we are over-Rxing antibiotics or another reason. What does this mean in terms of liability? Does this mean I can rely on the CENTOR criteria without any need for any sort of assay?

[cbrsmurf]

No monospot test either at one of the FP/UC places I work at (per MD's preference).

 

I am just wondering I should be pushing to get the rapid strep test (and monospot) at the clinic, cause I find myself Rx'ing more antibiotics for pharyngitis. I know that rheumatic fever is pretty rare in the US, but I don't know know if it's because we are over-Rxing antibiotics or another reason. What does this mean in terms of liability? Does this mean I can rely on the CENTOR criteria without any need for any sort of assay?

[EMEDPA]

centor is fine.

downside is lemierre's syndrome which should makes you think about rxing more abx, not less for really nasty looking throats even without + streps

see here:

http://en.wikipedia.org/wiki/Lemierre's_syndrome

[EMEDPA]

centor is fine.

downside is lemierre's syndrome which should makes you think about rxing more abx, not less for really nasty looking throats even without + streps

see here:

http://en.wikipedia.org/wiki/Lemierre's_syndrome

[Teasip]

Personally, I use the Centor scale (you can even add in the fifth modifier which allows for age and goes by another name). When you think about the big picture what are the ramifications of a missed strep pharyngitis? Rheumatic fever with inherent risk for RHD and PSGN (nephritis). Unless either of the two complications arise the disease itself is self-limiting and resolves over 5-6 days. Benefit of treatment is supposed decrease risk of infectiousness toward others and a mild improvement of overall symptomatology, thus the argument over steroid administration. If you look at the sensitivity of the Centor scale, having 4/4 criteria gets you a positive predictive value of just over fifty percent. Might as well flip a coin. There was an interesting article in an EM journal a couple of years back that gave the history of why we have jumped over barrels for strep when in fact we may have gone overboard instead. It had to do with a strep outbreak at a small military base in Wyoming, N. Dakota, or some such. It made for an interesting read and may be worth looking up.

 

Regarding mono, it can't be treated anyway so the rationale in my mind behind making the diagnosis is to appropriately educate the patient/family regarding the inherent risks including splenomegaly, hepatitis, encephalitis, as well as the infectiousness toward other individuals. The only benefit I saw from running an EBV/CMV titer panel was to be able to exclude the disease down the road if they had IgG antibodies to either, or hopefully both (as well as make the family feel better with a "diagnosis"). I've had a patient in the ED being seen for something else who had a LUQ scar from a splenectomy who ruptured it as a result of bumping his abdomen on the kitchen counter. My SP in that same ED had a college roommate who ruptured his while resuming light jogging (track team). As far as liability, if you miss the diagnosis and there is a complication then sure, there's always a risk, which is why I recommend educate, educate, educate. As long as splenomegaly is present, no exertional activities.

 

Speaking for myself, the ST that gets my attention is the normal appearing, normal speech, individual with a ST for several weeks without resolution. ENT consultation is recommended then. Also don't forget about the possibility of Ludwig's angina. I actually had such a situation myself several years back when following a URI resolution I had persistent left-sided throat pain. Saw ENT and was diagnosed with "Eagle syndrome". Good news is that he missed the diagnosis and that symptoms resolved with PPI/oral steroids and hasn't recurred since.

[Teasip]

Personally, I use the Centor scale (you can even add in the fifth modifier which allows for age and goes by another name). When you think about the big picture what are the ramifications of a missed strep pharyngitis? Rheumatic fever with inherent risk for RHD and PSGN (nephritis). Unless either of the two complications arise the disease itself is self-limiting and resolves over 5-6 days. Benefit of treatment is supposed decrease risk of infectiousness toward others and a mild improvement of overall symptomatology, thus the argument over steroid administration. If you look at the sensitivity of the Centor scale, having 4/4 criteria gets you a positive predictive value of just over fifty percent. Might as well flip a coin. There was an interesting article in an EM journal a couple of years back that gave the history of why we have jumped over barrels for strep when in fact we may have gone overboard instead. It had to do with a strep outbreak at a small military base in Wyoming, N. Dakota, or some such. It made for an interesting read and may be worth looking up.

 

Regarding mono, it can't be treated anyway so the rationale in my mind behind making the diagnosis is to appropriately educate the patient/family regarding the inherent risks including splenomegaly, hepatitis, encephalitis, as well as the infectiousness toward other individuals. The only benefit I saw from running an EBV/CMV titer panel was to be able to exclude the disease down the road if they had IgG antibodies to either, or hopefully both (as well as make the family feel better with a "diagnosis"). I've had a patient in the ED being seen for something else who had a LUQ scar from a splenectomy who ruptured it as a result of bumping his abdomen on the kitchen counter. My SP in that same ED had a college roommate who ruptured his while resuming light jogging (track team). As far as liability, if you miss the diagnosis and there is a complication then sure, there's always a risk, which is why I recommend educate, educate, educate. As long as splenomegaly is present, no exertional activities.

 

Speaking for myself, the ST that gets my attention is the normal appearing, normal speech, individual with a ST for several weeks without resolution. ENT consultation is recommended then. Also don't forget about the possibility of Ludwig's angina. I actually had such a situation myself several years back when following a URI resolution I had persistent left-sided throat pain. Saw ENT and was diagnosed with "Eagle syndrome". Good news is that he missed the diagnosis and that symptoms resolved with PPI/oral steroids and hasn't recurred since.

[akdEM]

There was an interesting article in an EM journal a couple of years back that gave the history of why we have jumped over barrels for strep when in fact we may have gone overboard instead. It had to do with a strep outbreak at a small military base in Wyoming, N. Dakota, or some such. It made for an interesting read and may be worth looking up.

 

There was an episode of the Smart EM podcast from a few years ago that referenced that same article. Apparently that base (I believe it was in Utah) was used to study rheumatic fever because there was an incredibly high rate, but we have never seen anything close to that in the general population. That doc on the podcast questioned whether that data is even applicable to the practice of everyday medicine. FWIW, he said that he almost never prescribes abx for pharyngitis, as the number needed to treat and relief of symptoms just aren't worth the side effects and risk of resistance. It might be a different story with peds, I do not remember. In any case, it's a great podcast and worth checking out!

 

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

[akdEM]

There was an interesting article in an EM journal a couple of years back that gave the history of why we have jumped over barrels for strep when in fact we may have gone overboard instead. It had to do with a strep outbreak at a small military base in Wyoming, N. Dakota, or some such. It made for an interesting read and may be worth looking up.

 

There was an episode of the Smart EM podcast from a few years ago that referenced that same article. Apparently that base (I believe it was in Utah) was used to study rheumatic fever because there was an incredibly high rate, but we have never seen anything close to that in the general population. That doc on the podcast questioned whether that data is even applicable to the practice of everyday medicine. FWIW, he said that he almost never prescribes abx for pharyngitis, as the number needed to treat and relief of symptoms just aren't worth the side effects and risk of resistance. It might be a different story with peds, I do not remember. In any case, it's a great podcast and worth checking out!

 

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

[Teasip]

Sounds like one and the same. I now think that the base was in Montana as I recall.

[Teasip]

Sounds like one and the same. I now think that the base was in Montana as I recall.

[True Anomaly]

That study is exactly why we made the push to give antibiotics to this condition.

 

EMEDPA pointed out something that should be more widely noted, and I'm embarrassed that I wasn't aware of Lemierre's syndrome prior to the SEMPA conference a couple weeks ago. Doc who gave the presentation made a very compelling case for being much more watchful of this than strep.

 

As to the original question, I also use Centor criteria and it works just fine. I've never used rapid strep in clinical practice outside of my student rotations.

[True Anomaly]

That study is exactly why we made the push to give antibiotics to this condition.

 

EMEDPA pointed out something that should be more widely noted, and I'm embarrassed that I wasn't aware of Lemierre's syndrome prior to the SEMPA conference a couple weeks ago. Doc who gave the presentation made a very compelling case for being much more watchful of this than strep.

 

As to the original question, I also use Centor criteria and it works just fine. I've never used rapid strep in clinical practice outside of my student rotations.

[cinntsp]

I know that rheumatic fever is pretty rare in the US, but I don't know know if it's because we are over-Rxing antibiotics or another reason. What does this mean in terms of liability?

 

The literature points to a greater risk of serious abx side effects(which is rare in and of itself) than the risk of rheumatic heart disease.

[cinntsp]

I know that rheumatic fever is pretty rare in the US, but I don't know know if it's because we are over-Rxing antibiotics or another reason. What does this mean in terms of liability?

 

The literature points to a greater risk of serious abx side effects(which is rare in and of itself) than the risk of rheumatic heart disease.

[ventana]

briefly

 

no - no problem

 

do the culture- call them with results - as long as non-toxic patient with out valve issues

[ventana]

briefly

 

no - no problem

 

do the culture- call them with results - as long as non-toxic patient with out valve issues

[Teasip]

http://www.sld.cu/galerias/pdf/sitios/apua-cuba/a34-evaluation_and_treatment_of_pharyngitis_in_primary_care_practice.pdf

[Teasip]

http://www.sld.cu/galerias/pdf/sitios/apua-cuba/a34-evaluation_and_treatment_of_pharyngitis_in_primary_care_practice.pdf

[ToBeWhole]

modified centor > strep test

 

in fact I ask the nurses NOT to order the strep test at triage

 

 

 

Sent from my iPhone using Tapatalk

[ToBeWhole]

modified centor > strep test

 

in fact I ask the nurses NOT to order the strep test at triage

 

 

 

Sent from my iPhone using Tapatalk

[Just Steve]

So I ask you this....if we depend on POC testing to determine our use or not use of antibiotics, why do we not trust this process to the technician or nursing level medical staff? If the POC test is the final determination, why not even trust this to a home health system, not unlike home HIV or diabetes testing?

 

My obscure point being is that haven't we advanced our medical knowledge, assessment ability, and critical decision making ability beyond dependence on a swab that in itself has a margin of error?

[Just Steve]

So I ask you this....if we depend on POC testing to determine our use or not use of antibiotics, why do we not trust this process to the technician or nursing level medical staff? If the POC test is the final determination, why not even trust this to a home health system, not unlike home HIV or diabetes testing?

 

My obscure point being is that haven't we advanced our medical knowledge, assessment ability, and critical decision making ability beyond dependence on a swab that in itself has a margin of error?

[EMEDPA]

So I ask you this....if we depend on POC testing to determine our use or not use of antibiotics, why do we not trust this process to the technician or nursing level medical staff? If the POC test is the final determination, why not even trust this to a home health system, not unlike home HIV or diabetes testing?

 

My obscure point being is that haven't we advanced our medical knowledge, assessment ability, and critical decision making ability beyond dependence on a swab that in itself has a margin of error?

the issue is that a lot of bad things happen in the throat besides strep. peritonsilar abscesses, etc and when you just check a strep and tx or not you disregard all other pathology.

[EMEDPA]

So I ask you this....if we depend on POC testing to determine our use or not use of antibiotics, why do we not trust this process to the technician or nursing level medical staff? If the POC test is the final determination, why not even trust this to a home health system, not unlike home HIV or diabetes testing?

 

My obscure point being is that haven't we advanced our medical knowledge, assessment ability, and critical decision making ability beyond dependence on a swab that in itself has a margin of error?

the issue is that a lot of bad things happen in the throat besides strep. peritonsilar abscesses, etc and when you just check a strep and tx or not you disregard all other pathology.

[Just Steve]

the issue is that a lot of bad things happen in the throat besides strep. peritonsilar abscesses, etc and when you just check a strep and tx or not you disregard all other pathology.

 

i agree completely...I wasn't very clear in my point...Perhaps my nativity is shining through but I think I would prefer to trust the judgement of a critically thinking clinician over the single vs double line of a swab.