I read the following opinion in the WSJ today and was reminded of a rather simple issue I see every day which is a kind of "fractaloid" mirror for the issues this post raises.
As you might imagine, I treat a lot of sore throat. I mean a lot. You might think illnesses like sore throat are simple, that all the issues around them are known, that something as trivial as sore throat should not raise any eyebrows. And as long as you cover over most of the details of the issues, you would be correct. But of course, the devil is always in the details. Further every detail can be approached from almost any viewpoint, and we all know this makes all the difference.
What is true for information as a whole, is just as true for the rabbit hole which is sore throat.
So let me jump to the answer for a moment: I do not think strep throat should be treated. While I would not say "ever", I would certainly say "most of the time". But let me also add that I always treat strep throat. In other words, knowing what I know, I continue to practice in a manner contrary to what I believe best. It is a most frustrating catch 22 for which I have no answer.
Let me explain by first stating a few "facts" everyone agrees on:
1. 90-95% of pharyngitis is viral
2. Except for a very few viruses, there are no specific anti-viral medications for viral pharyngitis
3. The sensitivity of rapid strep testing is about 80% (meaning 1 in 5 people with strep throat will have a falsely negative test even when they have strep pharyngitis)
4. Throat cultures are very sensitive (>90%) and considered a gold standard in diagnosing strep throat.
5. Throat culture results can take 3 days
6. If someone has strep pharyngitis, they can (should?) be treated with antibiotics
7. The antibiotic we use should usually be a penicillin derivative like amoxacillin (unless the patient is allergic).
Using these simple facts, which the medical profession unanimously agrees on, we of the medical cloth have developed decision/treatment algorithms any emergency physician/mid-level provider worth their salt knows backwards and forwardsfor. These algorithms represent a so called "standard of care"/"best practices"/"evidence based medicine" approach to care we should all follow accordingly. Hence I still treat strep throat. ;-)
So far I hope I have said nothing controversial.
The problem of course is that there is a problem. Lots of details were ignored by the people who made these recommendations- I do not suggest mean to imply this was done for nefarious reasons, they had to do it. And of course if you think about it much, points 6 and 7 are not really facts act all.
So if you look at points 1-7, a couple of thoughts should come to mind:
A. From whose viewpoint were these algorithms developed?
B. What were the assumptions that went into the observation/analysis/recommendations?
C. Why should we treat strep throat with antibiotics anyway?
This is a rabbit hole and the post would get very long if I dealt with even a few of these details/issues. As we are all busy, I will simply focus on points 6 and 7 the following way:.
Assume you have strep throat, a test has confirmed this and we believe the test results. Should you be treated with antibiotics?
My bottom line is "no".
It is VERY clear from data that the risk/harm of treating someone with antibiotics is one (maybe two) orders of magnitude greater than doing nothing at all. And yet the medical profession still treats strep throat. Indeed I still treat it stating what I believe to be true.
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