Tag Archives: Streptococcal pharyngitis

Consequences of Inappropriate Antibiotic Use

January 25, 2017Respiratory/Lungs, Infectious Disease, General Health and WellnessAntibiotic resistance, Streptococcal pharyngitis, Straight No Chaser, SterlingMedicalAdvice.com, Sterling Medical Advice, health, Common cold, Center For Disease Control and Prevention, CDC, Behind the Curtain, Antibacterial, American Academy of Pediatrics, 844-SMA-TALKJeffrey Sterling, MD

Introduction

This Straight, No Chaser discusses inappropriate antibiotic use.

We Want to Treat You!

Significant complications exist from missing any disease. If a heart attack is missed, your heart can rupture, and you can die. When a fracture is missed, you can develop necrosis, arthritis and loss of limb. If pneumonia is missed, you can go into respiratory failure and die. Etc., etc. As an emergency physician, my colleagues and I are more in tune than any other specialty of physicians with the risks and consequences of misdiagnosing critical illness; in fact it’s one of the main components of the speciality.

The point is giving medicine is not based on either fear or treating conditions that have a low probability of existing. Any physician is weighing the value of the information you provide to determine what appropriate management will be; that’s the Art of Medicine, and that will always be left to the individual judgment of your treating physician.

That said, the days of such absolute power by physicians are going the way of the dinosaur. Evidence-based medicine and outcomes-based medicine are here to stay. Multiple guidelines for best practices exist across many medical conditions, including when to order ankle x-rays and not, when to order neck x-rays and not, when to treat various infections and not. What’s new here is identifying opportunities to avoid exposing patients to unnecessary, costly medical interventions. What’s also new is you the patient can be better empowered and knowledgeable about the conditions you have and the care you receive.

Antibiotics Come with Risks!

The risk of inappropriate antibiotic use is more real, more present and more important than practicing defensive medicine.

There are classes of antibiotics that we can no longer use. I mentioned previously how Staph is resistant to several of the penicillins we’ve used for decades due to resistance, which occurs from overuse and inappropriate use, most frequently seen in treatment of viral illnesses. Yes readers, MRSA stands for methicillin-resistant Staph Aureus, and that’s why it’s known as a ‘super-bug’. Approximately 80% of those ear, nose and throat infections you’re coming to the emergency room for and asking/receiving antibiotics for are viral illness and would be better on their own in 48-72 hours.

Have you heard about what happened to gonorrhea due to inappropriate antibiotic use?

Similarly, treatment of gonorrhea has recently been revised by the Center for Disease Control and Prevention (CDC) because of the emergence of resistance to the medications used against it. Again, this has resulted from overuse and inappropriate use of these medications, largely in treatment of viral illnesses. One of the more powerful antibiotics we had at our disposal (a member of the fluoroquinolone class) just got pulled back from its 15 different indications for usage due to emerging resistance. This particularly powerful entity, instead of being withheld for serious diseases, was being used for urinary tract infections, minor skin and soft tissue illness and other conditions that eventually led to a loss of effectiveness. Why would such things be done? Profits and defensive medicine are two reasons that rapidly come to mind.

This is a lot more serious than just overusing medications. Sepsis occurs when an infection overwhelms the body and isn’t just limited to the local site where the infection originated. It can be so devastating that your body goes into shock, losing its ability to function and deliver blood throughout your body. Initial treatment of real illness suffers when we’re using medications that are less effective because bacteria have had time to mutate or otherwise become resistant due to non-lethal exposures.

The CDC and the American Academy of Pediatrics have consistently promoted this philosophy. It’s been included in JAMA, the Journal of the American Medical Association. Inappropriate antibiotic use has consequences!

Illnesses that Don’t Need Antibiotics

Consider the following lists of conditions that commonly can be treated without antibiotics.

Common colds and upper respiratory illnesses, including non-strep pharyngitis
Influenza (flu)
Most coughs and bronchitis (chest cold with a cough)
Many ear infections (also called otitis media)
Many skin rashes

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Straight, No Chaser: Inappropriate Antibiotic Use

January 28, 2016Respiratory/Lungs, Infectious Disease, General Health and Wellnesshealth, Common cold, Center For Disease Control and Prevention, CDC, Behind the Curtain, Antibiotic resistance, Antibacterial, American Academy of Pediatrics, 844-SMA-TALK, Sterling Medical Advice, Streptococcal pharyngitis, Straight No Chaser, SterlingMedicalAdvice.comJeffrey Sterling, MD

Whenever physicians attempt to discuss inappropriate antibiotic use with patients, too often fear replaces logic. These days, antibiotic use is treated as a convenience consideration, regardless if there’s actually a disease present that can be treated by antibiotics. Here are some principles your physician is mindful of when deciding if you actually need antibiotics.
Significant complications exist from missing any disease. If a heart attack is missed, your heart can rupture, and you can die. If a fracture is missed, you can develop necrosis, arthritis and loss of limb. If pneumonia is missed, you can go into respiratory failure and die. Etc., etc. As an emergency physician, my colleagues and I are more in tune than any other specialty of physicians with the risks and consequences of misdiagnosing critical illness; in fact it’s one of the main components of the speciality.
The point is giving medicine is not based on either fear or treating conditions that have a low probability of existing. Any physician is weighing the value of the information you provide to determine what appropriate management will be; that’s the Art of Medicine, and that will always be left to the individual judgment of your treating physician. That said, the days of such absolute power by physicians are going the way of the dinosaur. Evidence-based medicine and outcomes-based medicine are here to stay. Multiple guidelines for best practices exist across many medical conditions, including when to order ankle x-rays and not, when to order neck x-rays and not, when to treat various infections and not. What’s new here is identifying opportunities to avoid exposing patients to unnecessary, costly medical interventions. What’s also new is you the patient can be better empowered and knowledgeable about the conditions you have and the care you receive.

The risk of inappropriate antibiotic use is more real, more present and more important than practicing defensive medicine. There are classes of antibiotics that we can no longer use. I mentioned previously how Staph is resistant to several of the penicillins we’ve used for decades due to resistance, which occurs from overuse and inappropriate use, most frequently seen in treatment of viral illnesses. Yes readers, MRSA stands for methicillin-resistant Staph Aureus, and that’s why it’s known as a ‘super-bug’. Approximately 80% of those ear, nose and throat infections you’re coming to the emergency room for and asking/receiving antibiotics for are viral illness and would be better on their own in 48-72 hours. Similarly, treatment of gonorrhea has recently been revised by the Center for Disease Control and Prevention (CDC) because of the emergence of resistance to the medications used against it. Again, this has resulted from overuse and inappropriate use of these medications, largely in treatment of viral illnesses. One of the more powerful antibiotics we had at our disposal (a member of the fluoroquinolone class) just got pulled back from its 15 different indications for usage due to emerging resistance. This particularly powerful entity, instead of being withheld for serious diseases, was being used for urinary tract infections, minor skin and soft tissue illness and other conditions that eventually led to a loss of effectiveness. Why would such things be done? Profits and defensive medicine are two reasons that rapidly come to mind.
This is a lot more serious than just overusing medications. Sepsis is a condition where an infection overwhelms the body and isn’t just limited to the local site where the infection originated. It can be so devastating that your body goes into shock, losing its ability to function and deliver blood throughout your body. Initial treatment of real illness suffers when we’re using medications that are less effective because bacteria have had time to mutate or otherwise become resistant due to non-lethal exposures.

Consider the following lists of conditions that commonly can be treated without antibiotics.

Common colds and upper respiratory illnesses, including non-strep pharyngitis
Influenza (flu)
Most coughs and bronchitis (chest cold with a cough)
Many ear infections (also called otitis media)
Many skin rashes

To be clear, no one is recommending or promoting inappropriate or less than appropriate treatment of conditions that actually exist. No one is suggesting that anything you read here or anywhere else is more important than the real-time judgement of your physician. Just appreciate that opportunities exist to do the right thing and the wrong thing, and medicine is better with an informed patient.
Feel free to ask your SMA expert consultant any questions you may have on this topic.
Order your copy of Dr. Sterling’s new book Behind The Curtain: A Peek at Life from within the ER at jeffreysterlingbooks.com, iTunes, Amazon, Barnes and Nobles and wherever books are sold.
Thanks for liking and following Straight, No Chaser! This public service provides a sample of what http://www.SterlingMedicalAdvice.com (SMA) and 844-SMA-TALK offers. Please share our page with your friends on WordPress, like us on Facebook @ SterlingMedicalAdvice.com and follow us on Twitter at @asksterlingmd.
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Straight, No Chaser: Here's When Your Sore Throat Needs Antibiotics – The Centor Criteria

May 2, 2014Infectious Disease, Head/Eyes/Ears/Nose/Throat, General Health and WellnessStreptococcal pharyngitis, strep throat, Straight No Chaser, Sterling Medical Advice, lymphadenopathy, exudates, Conditions and Diseases, Centor criteria, Affordable Care Act, 844-SMA-TALKJeffrey Sterling, MD

I enjoy giving you tips that provide insight into what your physician is thinking. Some of these considerations are so simple that you can use them at home. In many examples, these can help you understand what to expect or even if a physician’s visit is even necessary.

For example, in revisiting sore throats, the big concern is whether you have strep throat. Not all sore throat are strep throat – in fact most aren’t. There’s scratchy throats from trauma, cigarette smoking and viruses, just to name a few non-strep throat causes of sore throats. As such, not all sore throats require antibiotics – in fact most don’t. However, all cases of strep throat require antibiotics. To not receive antibiotics for an actual strep infection can have devastating consequences, as discussed in this post.
Physicians use a set of criteria (the Centor criteria), based on clinical signs and symptoms, to identify the probability that your sore throat is strep throat. In case you’re wondering “Why not just do a test?”, the answer is those rapid tests done in the ER are very inconsistent and often inaccurate. Think about it this way: how still are you when someone’s sticking that swab in the back of your throat? Really, how persistent is your doctor or nurse in getting that swab all the way to the back of your throat? Many rapid strep tests are negative in the presence of real infection because the swab never got to the right area.

The criteria only involve four considerations. One point is assigned for each positive consideration.

History of fever above 101.4
Tonsillar exudates (those white patches you can see in the back of your throat)
Tender anterior cervical adenopathy (the swollen, tender “knots” in your neck found just about under the angle of your jaws)
Absence of cough (because the presence of a cough implies something else is occurring)

It’s worth noting that physicians may assign additional consideration to their decision to treat or not. If you’re less than 15, strep throat is more likely, and if you’re older than 44, it’s less likely.
The purpose of all this is it directs the need for testing and treatment.

0 or 1 points – No antibiotic or throat culture necessary, as the risk of strep infection is less than 10%.
2 or 3 points – You should receive a throat culture. You will be treated with an antibiotic if the culture is positive. The risk of strep infection here is 32% in the presence of three positive criteria and 15% in the presence of two.
4 or 5 points – You should receive antibiotics. The risk of strep. infection is approximately 56%.

Whether you use this information for a better understanding of what your physician is doing on to empower you in utilizing the healthcare system, it’s good to know. Now get back to avoiding strep throat in the first place!

Thanks for liking and following Straight, No Chaser! This public service provides a sample of 844-SMA-TALK and http://www.SterlingMedicalAdvice.com (SMA). Enjoy some of our favorite posts and frequently asked questions as well as a daily note explaining the benefits of SMA membership. Please share our page with your Friends on WordPress, on Facebook at SterlingMedicalAdvice.com and on Twitter at @asksterlingmd.

Straight, No Chaser: Simple Questions About Sore Throats

May 1, 2014Medical Treatment, Infectious Disease, Head/Eyes/Ears/Nose/ThroatSterling Medical Advice, Streptococcal pharyngitis, strep throat, Straight No Chaser, SterlingMedicalAdvice.com, mononucleosis, Conditions and Diseases, 844-SMA-TALKJeffrey Sterling, MD

Sore throats. So common. So simple. So sore. Here are a group of frequently asked questions to help you sort out the whys and what next considerations for you and your family.
How do I catch a sore throat?
You only “catch” them when the cause is an infection. Routine measures such as regular hand washing, covering your mouth when sneezing or coughing and keeping your hands out of your mouth go a long way to protecting you from infectious causes of sore throats.

Is a sore throat the same thing as tonsillitis?
Tonsillitis is one of many causes of sore throats. Causes can include infections, smoking, allergies and trauma to the back of your throat. Yes, bad singing can hurt more than someone else’s ears.
So what do I need to know about tonsillitis?
First you should know what and where the tonsils are. Besides being preferred landing spots for ice cream, the tonsils are the tissue located on both sides of the back of your mouth, as highlighted in the picture above. Tonsils are a common site for infection.
How is tonsillitis treated?
The treatment of sore throats in general is based on the cause. Tonsillitis can be caused by either bacterial or viral infections. Viruses do not respond to antibiotics, whereas bacteria do. Tonsillectomies are not needed in most people with tonsillitis. If you get severe tonsillitis often enough, or if you’re having breathing problems, you doctor may consider it.

Is strep throat the same as tonsillitis?
No. Strep throat is a sore throat caused by a specific type of bacteria (Streptococcus).

What is mono?
Mononucleosis (aka mono, the kissing disease) is a viral infection that causes sore throat. One clue that is very suggestive of the presence of mono is gland swelling in the back of your neck, as noted in the above picture.
Are sore throats dangerous?
It depends on the cause. If untreated, strep throat can result in dangerous disease of the kidney (called glomerulonephritis) or the joints and heart (called rheumatic fever). The complications of mononucleosis can be more serious that the disease, including splenic enlargement and rupture, as well as hepatitis (inflammation to the liver).
How does my doctor determine the cause of my sore throat?
Some physicians rely on clinical signs and symptoms. Others will obtain a throat culture or a rapid strep test. These tests are especially important if the decision is being made not to treat, because of the complications mentioned for untreated strep throat. Regarding mono, diagnosis may be confirmed with a blood test.
How are sore throats treated?
If your sore throat is caused by bacteria, you will receive an antibiotic. If it’s caused by a virus, you won’t. Antibiotics are ineffective against viruses. Just as occurs with other viruses such as the common cold, sore throats caused by viruses will go away on their own in 7-10 days.
Regarding specific treatment considerations:

If you have strep throat, your doctor will need to know if you’re allergic to penicillin.
No one under age 18 should take aspirin. Acetaminophen (e.g., Tylenol) or ibuprofen (e.g., Motrin, Advil) or naproxen (e.g., Aleve) can be given for relief of pain and/or fever.
If allergies are the cause of the sore throat, avoiding the causes is the most important consideration. Additional medicine for symptom relief is available.
Yes, gargling with warm salt water is effective. Place one teaspoon of salt in eight ounces of water.
Sucking on hard candy, throat lozenges, ice cream or frozen foods (e.g., popsicles) can help.
Drink plenty of fluids, warm or cool.
A humidifier is helpful for easing scratchy throats.

Another Straight, No Chaser post will address a simple way to figure out if your physician is likely to give you antibiotics for your sore throat.

Straight, No Chaser: Inappropriate Antibiotic Use

September 14, 2013Public Health, Medical Treatment, Infectious Disease, General Health and Wellness, Cardiology/HeartCDC, Antibiotic resistance, Antibacterial, American Academy of Pediatrics, Center For Disease Control and Prevention, Streptococcal pharyngitis, health, Common coldJeffrey Sterling, MD

Here’s a great concern regarding strep throat and the previous post that leads to a much more important topic (I’ll take the liberty of paraphrasing.): What about the concern of missing strep throat? Significant complications can result, including damage to the kidney (in a condition caused post-streptococcal glomerulonephritis). First I’ll address the concern, then I’ll get to the topic at hand.
Significant complications exist from missing any disease. If a heart attack is missed, your heart can rupture, and you can die. If a fracture is missed, you can develop necrosis, arthritis and loss of limb. If pneumonia is missed, you can go into respiratory failure and die. Etc., etc. As an emergency physician, my colleagues and I are more in tune than any other specialty of physicians with the risks and consequences of misdiagnosing critical illness; in fact it’s one of the main components of the speciality.
The point is medicine is not based on either fear or treating conditions that have a low probability of existing. Any physician is weighing the value of the information you provide to determine what appropriate management will be; that’s the Art of Medicine, and that will always be left to the individual judgment of your treating physician. That said, the days of such absolute power by physicians are going the way of the dinosaur. Evidence-based medicine and outcomes-based medicine are here to stay. Multiple guidelines for best practices exist across many medical conditions, including when to order ankle x-rays and not, when to order neck x-rays and not, when to treat various infections and not. What’s new here is identifying opportunities to avoid exposing patients to unnecessary, costly medical interventions. What’s also new is you the patient can be better empowered and knowledgeable about the conditions you have and the care you receive.
The risk of inappropriate antibiotic use is more real, more present and more important than practicing defensive medicine. There are classes of antibiotics that we can no longer use. I mentioned just this week how Staph is resistant to several of the penicillins we’ve used for decades due to resistance, which occurs from overuse and inappropriate use, most frequently seen in treatment of viral illnesses. Yes readers, MRSA stands for methicillin-resistant Staph Aureus, and that’s why it’s known as a ‘super-bug’. Approximately 80% of those ear, nose and throat infections you’re coming to the emergency room for and asking/receiving antibiotics for are viral illness and would be better on their own in 48-72 hours. Similarly, treatment of gonorrhea has recently been revised by the Center for Disease Control and Prevention (CDC) because of the emergence of resistance to the medications used against it. Again, this has resulted from overuse and inappropriate use of these medications, largely in treatment of viral illnesses. One of the more powerful antibiotics we had at our disposal (a member of the fluoroquinolone class) just got pulled back from its 15 different indications for usage due to emerging resistance. This particularly powerful entity, instead of being withheld for serious diseases, was being used for urinary tract infections, minor skin and soft tissue illness and other conditions that eventually led to a loss of effectiveness. Why would such things be done? Profits and defensive medicine are two reasons that rapidly come to mind.
This is a lot more serious than just overusing medications. Sepsis is a condition where an infection overwhelms the body and isn’t just limited to the local site where the infection originated. It can be so devastating that your body goes into shock, losing its ability to function and deliver blood throughout your body. Initial treatment of real illness suffers when we’re using medications that are less effective because bacteria have had time to mutate or otherwise become resistant due to non-lethal exposures.
The CDC and the American Academy of Pediatrics have consistently promoted this philosophy. It’s been included in JAMA, the Journal of the American Medical Association. Inappropriate antibiotic use has consequences!

Consider the following lists of conditions that commonly can be treated without antibiotics.

Common colds and upper respiratory illnesses, including non-strep pharyngitis
Influenza (flu)
Most coughs and bronchitis (chest cold with a cough)
Many ear infections (also called otitis media)
Many skin rashes

Straight No Chaser: About that 'Strep Throat'

September 14, 2013Pediatrics/Kids Health, Head/Eyes/Ears/Nose/Throat, General Health and WellnessThroat culture, Throat, Streptococcal pharyngitis, Sore throat, Methicillin-resistant Staphylococcus aureus, health, Evidence-based medicine, AntibacterialJeffrey Sterling, MD

Here’s a pretty common scenario. You’re a first time parent with the most adorable kid in the world. You’re in full tiger mom or dad mode, and you’re not going to let anything in the world hurt your baby. Your child has a sore throat, and you’re worried that it could be strep throat. You want to know if s/he needs antibiotics (Actually, you’re demanding antibiotics, but that’s another conversation!).
If a physician is actually using evidence based medicine to treat you instead of just throwing antibiotics at you to make you feel better (We call that ‘treating the parents’), there are criteria (based on what is called a Centor score) that determines when antibiotics are indicated and will make a difference (because most sore throats are caused by viruses and don’t respond to antibiotics; they’ll get better on their own in time). The Centor score is simple enough that you could figure it out yourself. Here are the components.
The patients are judged on six criteria, with one point added for each positive component.

History of fever
Tonsillar exudates (those white patches in the back of the throat)
Tender anterior cervical lymph nodes (those swollen lumps in the upper neck right below the angle of the jaw)
No coughing
Age <15 add 1 point (because strep is more likely at this age)
Age >44 subtract 1 point (because strep is way less likely at this age)

After that, you’ll have a number. Physicians use that number to guide management as follows:

0 or 1 points – No antibiotic or throat culture is necessary; the risk of strep. infection is less than 10%.
2 or 3 points – A throat culture should be done, and the patient should be treated with an antibiotic if the culture is positive.
4 or 5 points – The patient should be treated with an antibiotic (The risk of strep. infection is 56%), and no throat culture needs to be done.

So… if you do this calculation at home and get a 0 or 1, don’t expect antibiotics, and don’t get mad when you don’t get them. There are consequences to inappropriate usage of antibiotics. As I’ve discussed in the past (as with Staph becoming MRSA, for example), antibiotic resistance is a real phenomenon with dangerous ramifications for patients. At a patient, you really don’t want to take medications unnecessarily. Microorganisms develop resistance when you’re taking medications inappropriately. You want to remain such that when you need them, they work.
I’m happy to answer any questions or take any comments. Thank you.
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