A healthy 21 year old female presents with sore throat:
She has fever, sore throat, and anterior cervical lymphadenopathy. A rapid Strep test is positive and you’re happy to finally have one straightforward disposition on what has been an otherwise tedious shift.
Before you can click ‘sign orders’ on the LA Bicillin, a colleague looks over and says “oh, you still give antibiotics for Strep? That’s so 1990s…”
Are antibiotics indicated in routine cases of Strep pharyngitis?
Here’s what the CDC says: “Healthcare professionals can do a quick test to determine if a sore throat is Strep throat. If so, antibiotics can help you feel better faster and prevent spreading it to others.”
The IDSA (Infectious Disease Society of America) recommends: “Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days).”
WebMD makes their thoughts pretty clear: “…your doctor will likely do what’s called a ‘rapid Strep test’ to be sure it’s Strep. If the test is positive, medication can relieve the sore throat and other symptoms. Antibiotics are able to kill the group A Streptococcus bacteria that cause Strep throat. Doctors most often prescribe penicillin or amoxicillin to treat Strep throat. They are the top choices because they’re safer, inexpensive, and they work well on Strep bacteria.”
There is some controversy over whether antibiotics are necessary. So let’s review: what are the reasons to prescribe antibiotics?
#1, #2, and #3: Patient expectation
Ensuring that patients are satisfied with their care is important, but it should not happen at the expense of practicing good medicine. That being said, if a child has a fever and a positive rapid strep test, it’s going to take time and effort to convince the family that antibiotics aren’t necessary. It’s also going to lead to lower patient satisfaction scores, more patient complaints, and probably more [unncessary] return visits when the child’s fever doesn’t resolve within 24 hours.
#4: Prevent complications
The big bad complication of a true untreated bacterial pharyngitis is the potential to develop a peritonsillar abscess. Supporters of a no-antibiotics approach argue that PTAs are relatively easy to treat (aspiration/drainage) and that you would have to treat a hundred patients to prevent one case of a PTA. But can you imagine how that chart would look: you had a patient with a fever and pharyngitis on exam, a positive Strep test, and you discharged them without antibiotics – only to have the patient return one week later with an abscess? When you’re practicing against what the CDC and IDSA recommend, you don’t have a lot of room to stand on.
#5: Make children smarter
Children who are treated with antibiotics are able to return to school faster, making them more smarter.
Here’s what Medscape says: “Children treated with amoxicillin for Strep throat may return to school the next day without putting other children at risk for contracting the illness.”
And FamilyDoctor.org: “Children who have Strep throat should not go back to school or day care until their fever has gone away and they have taken an antibiotic for at least 24 hours.”
And a study published in the Pediatric Infectious Disease Journal: “Children treated for Strep throat with the prescription drug amoxicillin might be able to return to school the next day without putting other kids at risk for catching the illness…”
Simply put, failing to administer antibiotics throws a child’s return to school into question. At what point are they no longer considered infectious if they are not receiving antibiotics? No one knows, and there are no recommendations.
#6: Herd immunity
Some children might be ‘carriers’ of Strep, and prescribing antibiotics to everyone who tests positive is inappropriate. Or is it? Carriers have Strep bacteria in their throat, but it doesn’t necessarily make them sick. You’re unlikely to be ordering a rapid Strep test on someone who doesn’t have sore throat, fever, or pharyngeal exudate. But even if you did – and they tested positive – and they’re carriers, treating them can still help prevent the spread of infection.
#7: The elephant in the room
I’m not going to address the need to use antibitoics to prevent the potential development of rheumatic fever and post-strep glomerulonephritis. There are lots of blogs that do an in-depth job of debunking that myth (example: EverydayEBM post)
Conclusion
In my opinion, there are simply too many reasons to prescribe antibiotics to patients who test positive for Strep. I think that’s the gold standard and the way most of us practice. Hat tip to all of you evidence-based practitioners who use the latest studies to help guide their decision making, but the tide hasn’t turned for me (yet).
