Strep or Not: The Dance of the Worried-Well
I have been absolutely hammered in my clinical practice this week. I sort of expected it, since this is the usual pre-holiday rush. No one wants to be sick during an important family holiday where they may be traveling to points afar. This week was certainly the Dance of the Worried-Well — people that think they are sick, or concerned that they may become sick in the next few days. Yes, I am talking about the antibiotic-seekers.
Medical care is as much art as it is science. Medical science has performed modern miracles in the world of pharmaceuticals, diagnostic technologies, and unbelievable surgical treatments. In spite of those advances, it is still impossible to definitively predict if someone will become ill, or to treat a potentially-evolving illness now in order to guarantee that a person will remain well. Simple exposure to a biological insult (germs) does not necessarily imply that the exposed person will become sick. Every exposure... every person... and every immune system is different.
Strep throat infections are a prime example of this implied fear. A child wakes up with a severe sore throat and fever. Oh, my God. It could be the dreaded Strep infection. The family has plane tickets to leave the next day to visit the grandparents. In a panic mode, they show up at the clinic demanding to be seen. In our facility they really do not have to demand, since we have anticipated this with a program called Open Access. We have set aside dedicated appointment slots for this purpose and will see every person that walks through our door. On the days before holidays, most of my appointments are open. Keep in mind, that this child has only been sick for about an hour or so.
Strep tends to have a very characteristic appearance on clinical examination: a bright red throat with petechiae. Petechiae are tiny ruptured blood vessels that area as bright-red dots or a rash on the palate (the roof of the mouth directly above the uvula, also known by many patients as that "little hanging thing in my throat". The tonsils may be enlarged and red as well, but not necessarily exudative (that cheesy material that forms or collects on the tonsils). Children tend to be feverish and they may also have an upset stomach. Abdominal discomfort with Strep is relatively common in children; uncommon in adults. The lymph nodes in the neck may be enlarged and tender as well.
For experienced clinicians, Strep also has a characteristic smell. In severe infections, we can literally smell it when we enter the exam room. For some, we often get a good whiff when we look at the throat, or when (or if) we take a throat specimen for Strep analysis.
The Gold Standard for diagnosing Strep is the throat culture; a 100% accurate test that unfortunately takes about two days to complete. Rapid Strep Tests are commonplace now in clinics, but they are only about 80% or so accurate, depending on how carefully the specimen was collected (I like to do my own), and of course, how much Strep the person has at the moment. When a child has only been sick for an hour, the body really doesn't have enough time to (a) develop those characteristic clinical findings, and (b) colonize a sufficient amount of bacteria that can be easily detected.
When it comes to diagnosing Strep, there are many clinicians that feel they can just diagnose Strep simply by the examination finding. They are correct only about half the time. Knowing that 90% of all sore throats are not due to Strep (viral), some clinicians will still blanket-treat everyone with a sore throat with an antibiotic. This is really an irresponsible practice in light of the problems we are experiencing with overuse of antibiotics. Finally, there are clinicians (me) that only treat Strep when it is clinically-proven by an objective lab test AND corresponding clinical findings on examination.
When the Rapid Strep Test comes back positive, parents are happy, since the child will be treated. Their biggest fear is that we will tell them it is viral and they will leave without antibiotics. When the test is negative, and there are absolutely no clinical signs present to suggest a Streptococcal infection, then the ONLY logical and responsible course of action is to treat the symptoms; primarily the pain and discomfort. Even though it is no big secret that viral infections will not respond to antibiotics, many parents will still ask for them anyway. As much as I hate being the Antibiotic Nazi and tell them, No, I do have an obligation to carefully explain my rationale for this non-treatment. If a patient leaves unhappy and unsatisfied with their care, they will simply go somewhere else. There are plenty of medical providers out there that will simply prescribe an antibiotic when a desperate person begs or pleads.
Most sore throats, either from Strep or viruses, tend to improve on day three or four, a fact that often comes back to help or haunt us. For instance, if I see a person on day one (sick for one hour) and send them away with a diagnosis of a simple viral infection, they will continue to have a sore throat for another few days. An impatient patient may head off to the ER or urgent care on day two or three where an antibiotic is prescribed (unnecessarily). Lo and behold, they experience miraculous improvement the very next day! Even though patients would have experienced improvement anyway, they attribute the cure to the antibiotics that I would not prescribe.
There are no rules in medicine that state a person can only get one illness at a time. A child with a two day viral illness jumps on a plane for a five-hour flight to Grandma's. While on the plane, they lick the tray table, breathe everyone's air, and touch every surface in those tiny bathrooms. They arrive at their destination; a community filled with alien viruses that they have never encountered before. They are kissed and hugged repeatedly by loving relatives. Guess what? The next day they are sicker with a new illness. They may have even been newly-exposed to Strep since up to 20% of people are asymptomatic Strep-carriers. Parents drag them back to an Urgent Care and they are given an antibiotic... the same antibiotic that I refused to give them a few days prior.
The vacation is ruined and it's my fault. I have been found guilty in the Court of Parents without due process and no way to defend myself. Such is the double-edged life of a clinician.
Related Topics:
Technorati Tags: antibiotics, sore throat, strep throat
Medical care is as much art as it is science. Medical science has performed modern miracles in the world of pharmaceuticals, diagnostic technologies, and unbelievable surgical treatments. In spite of those advances, it is still impossible to definitively predict if someone will become ill, or to treat a potentially-evolving illness now in order to guarantee that a person will remain well. Simple exposure to a biological insult (germs) does not necessarily imply that the exposed person will become sick. Every exposure... every person... and every immune system is different.
Strep throat infections are a prime example of this implied fear. A child wakes up with a severe sore throat and fever. Oh, my God. It could be the dreaded Strep infection. The family has plane tickets to leave the next day to visit the grandparents. In a panic mode, they show up at the clinic demanding to be seen. In our facility they really do not have to demand, since we have anticipated this with a program called Open Access. We have set aside dedicated appointment slots for this purpose and will see every person that walks through our door. On the days before holidays, most of my appointments are open. Keep in mind, that this child has only been sick for about an hour or so.
Strep tends to have a very characteristic appearance on clinical examination: a bright red throat with petechiae. Petechiae are tiny ruptured blood vessels that area as bright-red dots or a rash on the palate (the roof of the mouth directly above the uvula, also known by many patients as that "little hanging thing in my throat". The tonsils may be enlarged and red as well, but not necessarily exudative (that cheesy material that forms or collects on the tonsils). Children tend to be feverish and they may also have an upset stomach. Abdominal discomfort with Strep is relatively common in children; uncommon in adults. The lymph nodes in the neck may be enlarged and tender as well.
For experienced clinicians, Strep also has a characteristic smell. In severe infections, we can literally smell it when we enter the exam room. For some, we often get a good whiff when we look at the throat, or when (or if) we take a throat specimen for Strep analysis.
The Gold Standard for diagnosing Strep is the throat culture; a 100% accurate test that unfortunately takes about two days to complete. Rapid Strep Tests are commonplace now in clinics, but they are only about 80% or so accurate, depending on how carefully the specimen was collected (I like to do my own), and of course, how much Strep the person has at the moment. When a child has only been sick for an hour, the body really doesn't have enough time to (a) develop those characteristic clinical findings, and (b) colonize a sufficient amount of bacteria that can be easily detected.
When it comes to diagnosing Strep, there are many clinicians that feel they can just diagnose Strep simply by the examination finding. They are correct only about half the time. Knowing that 90% of all sore throats are not due to Strep (viral), some clinicians will still blanket-treat everyone with a sore throat with an antibiotic. This is really an irresponsible practice in light of the problems we are experiencing with overuse of antibiotics. Finally, there are clinicians (me) that only treat Strep when it is clinically-proven by an objective lab test AND corresponding clinical findings on examination.
When the Rapid Strep Test comes back positive, parents are happy, since the child will be treated. Their biggest fear is that we will tell them it is viral and they will leave without antibiotics. When the test is negative, and there are absolutely no clinical signs present to suggest a Streptococcal infection, then the ONLY logical and responsible course of action is to treat the symptoms; primarily the pain and discomfort. Even though it is no big secret that viral infections will not respond to antibiotics, many parents will still ask for them anyway. As much as I hate being the Antibiotic Nazi and tell them, No, I do have an obligation to carefully explain my rationale for this non-treatment. If a patient leaves unhappy and unsatisfied with their care, they will simply go somewhere else. There are plenty of medical providers out there that will simply prescribe an antibiotic when a desperate person begs or pleads.
Most sore throats, either from Strep or viruses, tend to improve on day three or four, a fact that often comes back to help or haunt us. For instance, if I see a person on day one (sick for one hour) and send them away with a diagnosis of a simple viral infection, they will continue to have a sore throat for another few days. An impatient patient may head off to the ER or urgent care on day two or three where an antibiotic is prescribed (unnecessarily). Lo and behold, they experience miraculous improvement the very next day! Even though patients would have experienced improvement anyway, they attribute the cure to the antibiotics that I would not prescribe.
There are no rules in medicine that state a person can only get one illness at a time. A child with a two day viral illness jumps on a plane for a five-hour flight to Grandma's. While on the plane, they lick the tray table, breathe everyone's air, and touch every surface in those tiny bathrooms. They arrive at their destination; a community filled with alien viruses that they have never encountered before. They are kissed and hugged repeatedly by loving relatives. Guess what? The next day they are sicker with a new illness. They may have even been newly-exposed to Strep since up to 20% of people are asymptomatic Strep-carriers. Parents drag them back to an Urgent Care and they are given an antibiotic... the same antibiotic that I refused to give them a few days prior.
The vacation is ruined and it's my fault. I have been found guilty in the Court of Parents without due process and no way to defend myself. Such is the double-edged life of a clinician.
Related Topics:
- Antibiotics: Overused for Sore Throats?
- WebMD Magazine: Cold and Flu Survival Guide
Technorati Tags: antibiotics, sore throat, strep throat
9 Comments:
I thought strep must have a distinctive odor from the reaction the pediatrician sometimes has. It must be one of those things pediatricians get to know really well. I've been lucky that my kids haven't had strep often enough for me to be familiar with it though. Good thing. It seems like every time one of the kids got strep, I did too.
maybe you can help me. ive had strep like infections three times in the last 4 months, the most recent flaring up about 4 days ago and had me in a acute care clinic on an IV antibiotic. Its not strep, and hasnt tested postive for strep the last 3 times. ive known other people who have gotten this this year, and its the same deal, swollen tonsils, huge white patches on the tonsils, and incredible pain while swallowing along with fever. antibiotics clear it up in a couple of days, but its never strep. is this being talked about at all in medical circles? all the people ive known get it are my age, 18-22, and its all been the same symptoms and never tested positive for strep. anything?
Hi there,
Try using our Symptom Checker, which will lead you to articles that might help explain your symptoms. You can also post your questions to Dr. Moser on his Ear, Nose & Throat board.
Thank you, and happy holidays!
WebMD Blog Admin
Can a 59 year old person still get strep throat?
mom of 4 asks:
can a child who has had their tonsils & adnoids removed still get strep??????
Most Excellent Advice and a good read. It is about time a doc has the balls to tell folks reality like like it really is. Two comments if I may. 1), Dry Air may also lead to a sore throut/extreemly sore uvula. (it stuck to my tounge, when I cleared my throught, !! well you get the pic. still recovering - i) oh and 2), Please inform your webmaster that it took 20 minutes to 'teach' my web browser to get the JavaScript/JAVA apps to 'not visually block' the rest of the page, and yes, (we are using the most currenty compliant browser.) So, Thank You and Kudos, Salt water gargle Etc., DOES work! Thank You for Being Real, and convincing me NOT to *snip* moi 'uvula out' as I wanted to, (and hence going to one of our locally factidious hospitals :)) .. You May Edit thus, and please excuse moi spelling. And Again, Thank You. You Have Helped at least ONE folk (me) from doing something stupid (and bleeding to death maybe, according to my family). Again, Thanks. :)
This sounds real close to what I experienced. I'm a 39 y/o male and I don't think I'd ever had Strep before. I went to my Primary doctor on Friday complaing of a sore throat. He did a quick-check of a throat culture, told me I didn't have Strep and it would go away in a couple days. Sunday morning, I'm at Urgent Care with a 100 degree temp and the results of their quick-check cultures shows I have Strep. I'm 4 days into my antibiotics, but I think my hearing may have been affected somehow. I have a loud ringing in both my ears - at one point I lost hearing in my left ear for a couple hours. Is it possible the fever or infection could have caused this and whould I get this looked at?
I thought this Dr.'s letter came across like a grumpy old doctor. Maybe if he spoke to his patients in the same tone, he could retire early because lack of clients.
KJW Arizona
exactly - the last person had it right - how arrogant to think it is all about him. Where are parents supposed to go to know if they have a problem or not - the supermarket or the doctor. Most are NOT antibiotic seekers - they just want to be prepared for their trip. Perhaps identify a local MD at their vacation site if needed or maybe catch the problem before they go. Some doctors are a bit to self-important these days. Also - why shouldn't parents have all their bases covered before they leave it called being prepared. Believe me, no parent wants to go the Doctor's office. I really don't believe most Pediatric docs believe what this one does. Also - any time you can lessen the symptoms - the better everyone will be - the whole family does need to rest/sleep to get better.
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