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Strep Throat Part 2

Casey Parker, MD
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Would you ever consider NOT giving antibiotics to a patient with strep throat?

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Kelly A. -

Great segment! What is the pathophysiology behind the different rates of RF in the two different populations in Dr. Parkers region? I get that one population is generally in poorer health. But why the difference with regards to the RF rates?

Casey P. -

Hi Kelly
Great question - a tough one to answer. In summary: it's complicated.
There are still a number of proposed theories about the exact pathogenesis of rheumatic fever / heart disease.
Most folk seem to think it is due to molecular mimicry - i.e.. an immune reaction to strept M protein which looks like valvular endothelium, synovium etc to the immune system. So it is an autoimmune process triggered by exposure to streptococci - presumably some strains are more virulent / provocative than others.

So why the different rates? Well my reading suggests that one needs multiple / repeated infections to set up the immune response that causes the symptoms that we see - e.g.. the Jones criteria.

Well, healthy kids in western countries may be exposed once or twice to invasive strains. But kids who live in overcrowded, malnourished homes are prone to frequent repeated infections which set up this immunological response to native tissues.

Here are some references, review articles:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3645882/
http://www.ncbi.nlm.nih.gov/pubmed/24892819

There is some evidence to suggest a genetic component to the disease as well - so that may be why we see it in some Indigenous populations where the phenotypes assoc with ARF may be concentrated.

Hope that helps - it is not really clear in the primary scientific data.
Casey

Kelly A. -

Thank you.

mike p. -

Is there a time where you suggest always, sometimes or never doing a culture for a negative rapid tests? Only in select cases where your pretest probability is higher but don't want to necessarily treat empirically? In the US, guidelines recommend against empiric treatment based on exam as CENTOR criteria aren't that accurate but rather suggest only treating with a positive rapid or culture.

Casey P. -

HI Mike
Thanks for the question. As I said in the podcast - I don't do swabs really ever - RADT or formal cultures. So I will have to imagine I work in the US of A to answer this one!
So if you get a negative RADT in a patient with a reasonable history / exam for street throat (i.e Centor > 2) then will adding a formal throat culture help pick the true street throat? OR is it unnecessary ? There are a few questions here:

1) What is the extra "pick up rate" or accuracy of culture over RADT?
2) Will detecting the street actually translate into a meaningful intervention for the patient?

Here is a nice met analysis from he US Journ of Paediatrics [ http://pediatrics.aappublications.org/content/134/4/771.short ] which says: "Overall summary estimates for sensitivity and specificity of RADTs were 0.86 (95% CI 0.83 to 0.88) and 0.96 (95% CI 0.94 to 0.97), respectively, and estimates for pediatric data were similar"
So I guess that is pretty good - but not perfect - they recommend against a subsequent culture in their discussion.

The second question is tougher one to answer. The PRISM trial tried to answer it as discussed on the podcast.

So if I were an American Family doc practicing in a community with low [actually extremely low] incidence of rheumatic complications. I think you need to ask WHY am I swabbing / treating? It should not be to prevent acute rheumatic fever - that is a really low yield strategy.

So I think it comes down to deciding who you will treat for symptomatic relief.

I would have the discussion with the patient / parents about options for symptom control other than ABs, discuss the relative risk: benefit of ABs and if they still wanted to go ahead with AB treatment - you could swab (or RADT) those kids and about half of them would be negative - so you could avoid ABs in those kids.

As Rob mentioned - I am an antibiotic minimalist - so you should be aware of my personal bias. Understanding the background risk of severe sequelae in your community is vital. Only then can you get a feel for the importance of acting / investigation or treating.

Oh - and the Australian guidelines also say similar things - but when you read the primary data on which they are compiled- it doesn't really stack up. So this is a great example of Family docs needing to go beyond the guidelines to make sensible choices with the patients.

Casey

Manju M. -

Thank you for sharing this wonderful information with us. I am a recent graduate of family medicine residency and took up a job in a rural/under-served area. I continue to struggle with the antibiotic battle everyday. I totally agree with your views that abx are way overprescribed without looking in to the actual benefits. In my few months of experience I have had patient/parents getting angry over not prescribing abx for strep or even just for a sore throat. I attribute some of this to the practice of other providers who have been working in this area for many years and have a very low threshold of prescribing abx. In my community patients are conditioned to take abx for sore-throats, colds and bronchitis. In a busy clinic setting where there is a pressure of seeing a lot of patients in a day, it gets increasingly difficult to talk patients out of demanding them especially when they can easily go to the other provider and get an antibiotic in a jiffy! I often wonder if there is a solution to this problem.

Kelly A. -

I am with you. The antibioticphilia is prevalent to the nth degree in my community. There is pressure from the clinic manager to keep patients happy, after all it is a business. If they don't get their antibiotics here they just drive to the next clinic and receive them there as in your community. We have posters posted like wall paper about antibiotic resistance, no antibiotics for common colds, ect. My newest line goes something like this: bla bla bla (evidence based studies) - and then - "it's easy for me to write a prescription and get you on your way, so why would I make it more difficult and time consuming for myself if I did not care or did not believe this is an important issue". So far it is the same - "well all I know is I take a Zpak and I feel better the next day". Patients will not touch gluten with a 10 foot pole but they need their Zpak. Sorry for the rant, keep fighting the fight. Just remember, there are not such thing as viruses and all sore throats are strep - wink wink.

Casey P. -

Hi Manju

Yours is a common problem the globe ( first world part) over!
I also have struggled with this for a decade. But the tide is changing in my world
I have a 3 pronged approach

1). Good, evidence based public information. I do a segment on our local radio station on health and frequently push the harms of antibiotics in minor ailments. Your clinic / hospital should try and have info leaflets in the waiting room to allow pts to read as they wait and the conversation becomes easier.

2). Work on your colleagues - use education sessions, share papers, suggest podcasts like this one! Having standardised advice from all providers is key.. Patients are confused who they get different advice from each doctor they meet.
I recommend that you sit down with your group, local colleagues and have a discussion about best practice using the best available evidence. This is tough - changing doctor thinking is hard. Show a narrative of bad outcomes from antibiotics - we all love. A terrible story.

3). Use empathy. Patients are suffering - they want you to help them. They have been conditioned to think that antibiotics are the solution. You need to show then you understand that they are suffering, offer them an alternate solution - steroids, NSAIDs whatever - a real plan. Then separate the idea of ABs from the concept of pain. Say " so the plan for your pain is x, y and z.... And if you like we can discuss what antibiotics may or may not do for you.

I think you need to accept that this is a 5 year deal. It takes a while for parents to learn that their kids will be fine without antibiotics. It's a marathon not a sprint!
Go well mate

Casey

Vanessa C. -

Really interesting segment Casey... Interested to hear about the variations of strep and ARF that you encounter based on the background of the patient. I work on a Cree reserve in remote Canada and the rates of strep (granted high carrier rates) and peritonsillar abcesses are alarming. It always stuns the students and residents who come to visit us to see the rates and severity of disease in all age groups. Don't see a lot of ARF though. Very crowded living conditions... often several people in one bedroom, 10-12 in a 2 or 3 bedroom house.

You mentioned that you are an antibiotic minimalist but that you will give antibiotics to the high risk group without swabbing. Just wondering what resistance rates are like in your neck of the woods?

I would love to get away from giving so many antibiotics but it is going to take a very long time to "re-educate" the population that while we used to say antibiotics were only for bacterial pharyngitis now we are trying to avoid them all together if possible. Like the idea of a group approach though. We certainly run into that problem where one or two docs always give antibiotics for clearly viral URTIs so the rest of us are fighting battles with patients on every shift.

One last question... you mentioned a few times the two different parts of your department... are the Aboriginal patients treated in a different location than non-aboriginal patients? We have one reserve which is half Cree and half Inuit and the clinic building is split into two... Crazy waste of resources in our case... Curious how it works in your neck of the woods/desert.

Casey P. -

Hi Vanessa
Second question first - no one big happy ED!
Our Aboriginal patients have access to a free clinic down the street 9-5, but still a lot are seen in our ed I.e. 2/3 of our patients are true locals.

I give ABs up front to kids at risk as there is no facility to follow up or chase results really - and the net effect would be too many misses I think. Swabbing adds another expense, difficulty to an already tough case load. I think the risk: benefit is tilted towards treatment in high risk kids.
Having a "hospital policy" for Abs does two things
1 - allows clinical leaders to formalise "best practice" for the group - that way anyone who doesn't follow the policy is doing so at their own risk
2 - allows us to say to parents : AB prescription is not the hospitals policy - " hey, it's not my call - the smart Docs have decided your child doesn't need em! ". Allows you to keep therapeutic relationship instead of argue the merits with each parent

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Strep Throat burns out the Gout! Full episode audio for MD edition 190:58 min - 90 MB - M4AHippo Primary Care RAP March 2015 Summary 430 KB - PDF

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