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Thursday, November 19, 2009

The problem with strep throat

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.



Thai said...

hint (and to receive comments): antibiotics can be bad for your health.

Street Dog said...

There are analogies...uhhh metaphors...uhhh analogies...uhhh similitudes throughout medicine. Thai knew that I could relate on this one. To further complicate this theme, a patient with proper informed consent will make treatment decisions influenced by intellectual/emotional issues that are particular to their aspect. For example, an uncommon but unpalatable natural outcome may overwhelm the patient intellectually/emotionally in comparison to treatment side-effects.

Indeed I still treat it stating what I believe to be true. Why?

Ahh, the crux of the post. My best answer is too long. It takes into account the limitations of medical knowledge, the importance of informed consent, the importance of self determination (not self harm), societal/professional expectations of physicians, intellectual/emotional impact of different outcomes, including the differences between medically induced harm and naturally occuring harm (disease), ...I'll stop. Thinking about this theme for years has affected the way I approach medical treatments and especially surgery. Hint: surgery can be bad for your health. Primum non nocere

Thai said...

"Thai knew that I could relate on this one"

Welcome my friend, and I truly mean that.

All the rest


Debra said...

Funny you should bring this one up, Thai.
The powers that be in France have spent mucho mucho filthy lucre in the past 3-4 years doing massive public health campaigns to target G.P.'s with the idea that indiscriminate antibiotic prescription is counterproductive and leads to problems of resistance later down the road.
We are fast moving from one dogmatic position to another (ALWAYS treat with antibiotics to... NEVER prescribe them).
Why do we treat with antibiotics ?
I think I can give you an excellent... PSYCHOLOGICAL reason (remember the whole system bottoms out because the powers that be ASSUME we are rational, and they do this out of a terminal case of.. WISHFUL THINKING) for this.
Doctors prescribe because.... it makes the patient feel good knowing that something is being done, and popping a pill is doing something. It is... ACTIVISM, and EVERYBODY wants to be active in the face of illness, not sit and... WAIT to see what happens.
And, of course, doctors like to be active too. They like to be useful because they're... doing something, right... not waiting either.
Remember what I said about the injured coming back from war. The ones who have... lesions that can be treated by the doc do better than the ones who DON'T have lesions.

Dink said...

I do not think strep throat should be treated. While I would not say "ever", I would certainly say "most of the time".

but, but, but.....(Dink reeling from rabbit heresy). Even after determining the sore throat is strep vs. viral you don't think it should be treated? I thought strep was the Great Satan; eating heart valves and nephrons and meninges and had to be stopped by any means necessary! Terra Firma is eroding underneath my paws...


Someone once told me that the resistance is so established to this antibiotic that it is only left in production as a placebo to prescribe to the kids of hysterical parents who don't understand viruses, but demand "something be done".

Previous comment sections:

* Zimbabwe, not Japan. The U.S. collective is not very collected, imo. Japan has strong behavioral norms supported by deeply entrenched individual shame/pride. The U.S. and Zimbabwe seem, how shall we say, laissez-faire. For better or worse; the good times being more fun than the good times in Japan.

*Nylonase: hadn't realized it existed! Also just became aware this week that some Swedes are immune to HIV because of some genetic mutation that probably resulted from their ancestors surviving small pox. Sci can get weirder than sci fi, no?

The use of bacteria to create a fractal analogy to create a common conceptual language came to me from hearing about people taking antibiotics to cure one microbe only to then be infested by fungus. It seemed to provide a nice tangible example of sugarscape, energy conservation, unintended consequences, etc.

*Retinas. My optometrist e-mailed me a picture of my retinas from my last exam. It was absolutely normal so there was no reason for me to have it, but I think he sensed my geekiness and guessed I would want it ;)

Thai said...

Well said Deb

Indeed, don't treat it.

The data on the subject simply does not add up.

1. Some studies have suggested 3% of untreated strep pharyngitis develop acute rheumatic fever (ARF)


2. There are something like 10 million sore throats in the US/year
3. 60% of all kids will test positive for strep once a year.
4. 1/2 of kids testing positive are really just strep carriers
5. Treatment will not end carrier states
6. 90-95% sore throats are viral

You do the math...

And yet:

1. The prevalence of ARF in the developed world is now around 1/100,000 (it is much higher in the developing world and amongst aboriginal Australians, so my recommendation to not treat confirmed cases of strep pharyngitis is with a big caveat of "it depends where you practice medicine").
2. Treating confirmed strep pharyngitis with antibiotics improves resolution by an average of only 16 hours.
3. C. diff diarrhea is a very real risk from antibiotic therapy- up to 3-4% in some cases. Though there are Canadian studies which suggest that at least in the community setting, antibiotics are a smaller factor than we think... this issue is controversial and complicated issue

And there are other potential complications to throw into the decision such as the risk of developing peritonsilar abscess, incredibly low but real, etc...

My point is that when you look at the issue closely, it is a rabbit hole but I think the balance on data is strongly on the side of not treating.

But if I don't treat, how happy would my patients be? How much time would I need to explain this to them? What about the 40 other patients who are in the waiting room angry they have not been seen in 6 hours?

Yet should this play a role in my decision to not treat- my time?

And if I spend the time, how often will they believe me? What if they complain? What if they accept my "no" but then in nervous second guessing decide they want a second opinion? A second opinion for strep throat? What about all that time and $ wasted?

The permutations on this issue go on and on and on.

And so I treat, it is what everyone does. I am not sure it make sense we all do it, but no man is an island and this is just as true in medicine.

Or we could spend an enormous amount of time and money educating everyone on this issue- fine?

But where does that money come from ? What else will we give up in order to pay for this?

Or we could just trust our physicians to make the right decisions. But what is this is a bad idea? They can make mistakes like everyone else.

And so I treat it and wait for other battles to pick.

Thai said...

re: "Also just became aware this week that some Swedes are immune to HIV because of some genetic mutation that probably resulted from their ancestors surviving small pox. Sci can get weirder than sci fi, no?"

By the way, you probably already know but just in case you do not, this issue is fascinating from so many angles. I do not know how closely you are following the gene therapy/"modification" issues (I fear Deb may get upset on this issue so I might need a bit of catnit at my side), but a variant on this issue and the very genetic immunity to HIV you mention has already been successfully clinically tested.

Seems a far cry from the tragic death of Jesse Gelsinger at U Penn... in one of those "what a small world" issues, it turns out my wife worked in that very lab as an undergraduate in the mid 80's).

And to be fair to Penn today- perhaps our resident ophthalmologist can share more- they have made serious progress since their initial setback.

I tip my stethescope to these guys.

Indeed it is nice to know as a provider on the front lines that while we hold the fort from collapsing, the other players on the team are in position as well.

We Americans may not be Japanese, but we are not totally without teamwork either. ;-)

Thai said...

Sometimes I feel the need to personally take a shower in this whole mess.

Understand that while I do agree with what congress did- not that such a view would be selfishly motivated in any way ;-)

Still this whole approach is crazy and this is most certainly not the way to do it. At least not where we are all looking out for each other.

Oh well, it is what it is

Debra said...

On the subject of... treating and not treating, Thai, I think that we may have some major differences...
Two years ago on my previous loony forum, I got kicked off after getting VERY WORKED UP about what the docs are now doing to try to.. predict (oh, that ugly word, that incredibly ugly word...) and prevent mental illness early on in the game.
This issue is a zero sum one which is very very close to home to me.
When my eldest was born (21 now...) I was a basket case. Very very depressed. With suicidal tendancies, and low key delusions. I had a very hard time taking care of him, and he developed... some symptoms that you can see in babies whose mothers are very very depressed. You know... the kind of situations where, in poor families, the social worker marches in and, in an authoritarian manner, confiscates the kid and farms him out to an institution. Major proof that inequality exists is that the poor get picked on, but... the rich get off on this one...
But... as the years passed, and my son got into school, and I started meeting people and being less isolated, he pulled through. And he is now in his fourth year of medical school.
So, Thai.... this is what's so interesting about the.. primo non nocere idea. I am willing to put my life on the line that... he is better off now in spite of the bad start he may have gotten than if he had been pulled out of our home for his own protection and farmed out to someone else, or an institution.
Care on commenting on this one ? Be careful...

Thai said...

I am not sure what you think I believe re: treatment of mental illness to make such comments but I suspect you may be in the wrong ballpark.

1. Did your son really get a bad start? The devil is in the actual details.
2. Taking a child out of a home is most definitely what I would call an intervention.

I already said I don't think we should intervene with antibiotics for strep throat, so why would I be more casual about removing a child from his/her home than using antibiotics? If you think I worry about C.diff from antibiotics, what kind of complications do you think I might also be worried about with infant-parent separation?

And sadly I have to make this call to CPS (child protective services) many times. I will say that in 80% of instances, I make the call not because I feel it critical but instead because of legal mandates placed on physician practice patterns (regulation gone amuck in my opinion- trying to turn a medical system which is like English common law into a system like the Napoleonic code).

It is rare I truly think CPS can make the situation better... And to be more precise, there are times when removing a child from a home literally is the difference between imminent life and death.

Another rabbit hole of messiness.

As always, "it depends"

Does this answer your question?

Debra said...

I read you wrong, Thai. I'm sorry.

Thai said...

There is no way you are a bad mom so stop beating yourself up. Everything in society is non-linear, yet we keep on insisting as a collective that we live in a linear world.

Trust me, I see bad moms, I really really do.

No way

Street Dog said...

I can tell that behind those scary feral claws, there is a tigress with a big heart that is proud of her little cub.

Thai said...

As she should be

Debra said...

When is the last time you saw a tigress do that ? ;-)

The Most Fabulous Objects In The World

  • Hitchhiker's Guide To The Universe trilogy
  • Lord of the Rings trilogy
  • Flight of the Conchords
  • Time Bandits