In the past week, there has been some national buzz around: “Why strep throat is causing serious complications, from amputations to death”. This is quite a headline, especially for those in the emergency medicine community who are moving more and more towards a practice of not routinely treating strep pharyngitis with antibiotics. I can already picture some of our patients rushing to the ER at the first sign of a sore throat, with a copy of this article in hand.
Can you blame them?
What’s the evidence?
It doesn’t help when medical professionals can’t seem to agree amongst themselves on how to treat patients with possible strep pharyngitis. A few years ago Anand Swaminathan had written a very succinct argument on this very topic. Antibiotics are associated with very real and tangible complications and the studies that originally supported their routine use for strep throat were fraught with problems. His clinical bottom line?
“We are far more likely to harm patients with strep pharyngitis by giving antibiotics than to help them in developed countries.”
While many EM physicians have begun shifting towards this practice – especially amongst our trainees, who utilize social media based resources more and more – this is still in stark contrast to many published guidelines. The Centre for Disease Control (CDC) states that “Antibiotic treatment is indicated for patients, regardless of age, who have a positive RADT or throat culture”.
The Infectious Diseases Society of America (IDSA) clinical practice guidelines for strep pharyngitis 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). Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents (strong, high)”.
The latest Cochrane review (2013) on this topic reported that the number needed to treat to benefit (NNTB) to prevent one sore throat at day three was less than six. They also found that antibiotics reduced the incidence of acute otitis media within 14 days (RR 0.30; 95% CI 0.15 to 0.58); acute sinusitis within 14 days (RR 0.48; 95% CI 0.08 to 2.76); and quinsy within two months (RR 0.15; 95% CI 0.05 to 0.47) compared to those taking placebo.
But there are problems with guidelines. An interesting study published in 2007 compared the recommendations and the reported evidence in international guidelines for the management of sore throats. The authors found huge heterogeneity in how guidelines from different countries and medical bodies were developed. Most concerning, they found significant selection bias and differences in interpretation of scientific evidence: “National guidelines on acute sore throat promote different clinical approaches, recommend different treatments, and cite different evidence”.
What should we do?
You can begin to see how the frontline EM physician may feel like being caught between a rock and a hard place. On the one hand, severe complications from strep throat is exceedingly rare (even the Global News article report an incidence of 3.5 in 100,000), and the effectiveness of antibiotics were based on very old studies of questionable rigour. Additionally, it appears that with improvements in sanitation in developed nations, the risks and complications from strep infections have decreased significantly. On the other hand, all the major North American Infectious Diseases guidelines clearly recommend treatment with antibiotics, not to mention sensational news articles of some very bad outcomes.
So in retrospect, is it really fair to blame the patients and their so-called “unrealistic” concerns and demands? Can we really fault the media for reporting on cases of amputations and deaths resulting from strep infections?
The battle for more appropriate antibiotic use and stewardship does not rest solely at the frontline during that 10 minute ER visit, nor can it be won by casting outrage at the inevitable media reports of bad outcomes. The real battle is getting the medical profession moving in the same direction, and investing in the development of high quality evidence. Perhaps when patients do present to the emergency department with these concerns, we can engage in some shared decision making and have an open discussion with them regarding the controversy of the literature.
Another important consideration that this article brings up is that physicians are commonly influenced by anecdotal evidence, so it should not be surprising when such sensational news articles encourage patients in a similar manner. Understanding the issues surrounding anecdotal evidence will also help practitioners to engage in appropriate conversation with their patients in a more meaningful manner.
What is your current practice with regards to strep throats in the emergency department?