DOI: 10.1097/01.EEM.0000421440.62575.fc
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Issn Print: 1054-0725
Publication Date: 2012/09/20
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Excerpt
Value medicine stops asking the question, “What is the best?” and instead asks, “What is the value?” Value medicine has four components: the magnitude of benefit, the magnitude of harm, the magnitude of patients unaffected, and the charge to the patient (and cost to society). These are negotiated by shared decision-making.
The party line given in the ED for using antibiotics for strep throat is that they prevent acute rheumatic fever and peritonsillar abscess and reduce the spread of disease and symptoms by about one day. None of these assumptions is true, but if they were, they are clinically irrelevant for most patients.
Antibiotics do not prevent acute rheumatic fever in the United States. The ability for group A beta-hemolytic strep (GABHS) to cause rheumatic fever depends on a strain infrequently found in the mainland United States; it has not caused an epidemic since the 1980s. The current incidence is less than one per 100,000 population. (World Health Organization, 2001; Clin Infect Dis 2006;42[4]:448.) It would be impossible to affect such an infinitesimally low incidence with antibiotics.
Antibiotics do not prevent peritonsillar abscess either. The majority of patients with peritonsillar abscesses have negative rapid strep tests, and a majority of patients with abscesses are on antibiotic therapy that covers strep. (J Laryngol Otol 1991;105[7]:553; Fam Pract 1996;13[3]:317; J Fam Pract 2000;49[1]:34.) Fairly good evidence shows that rapid testing and antibiotics do not prevent peritonsillar abscess.
Antibiotics may decrease symptoms only if given early, but who cares? Articles published in the 1980s and a few recent reviews show an advantage of antibiotics if given early after symptoms appear (J Pediatr 1985;106[6]:870; Pediatr Infect Dis 1984;3[1]:10; JAMA 1985;253[9]:1271; BMJ Med 2000;320[7228]:150), but there are several problems with this apparent benefit. Most patients do not present to their doctor on the first day of symptoms, and it is not clear that antibiotics provide any symptom benefit if they present on day two or three. And the primary symptom is pain, and no data have compared analgesia with an antibiotic and analgesia. It is common sense that an antibiotic may be irrelevant if you have good analgesia. Symptoms for 16 to 24 fewer hours does not necessarily translate into returning sooner to school, work, or activity.
Antibiotics probably don't decrease spread of disease. Twenty-four hours of antibiotics do reduce the recovery of GABHS from cultures of the pharynx, but this is a surrogate marker, not the same thing as 24 hours of an antibiotic decreasing spread (which is the way these data are often translated). These are different for several reasons. Most patients have symptoms at school or work before they receive antibiotics, and they have likely already spread GABHS. Many patients also are treated empirically with antibiotics for presumed GABHS. The majority of these patients have a virus; even 50 percent of adult patients with four of the four Centor criteria have a viral illness. (J Gen Intern Med 2007;22[1]:127.) Returning patients prematurely just because they have had an antibiotic for 24 hours will actually increase the spread of viral disease. Many patients are tested with rapid streps to determine whether they are candidates for antibiotic treatment; unfortunately, the rapid streps performed in a community setting falsely reassure patients and parents more than they accurately treat.
Thirty percent of culture-proven GABHS patients tested with “rapid strep tests” have an initial negative screen in clinical community studies. (Pediatrics 2009;123[2]:437; Clin Microbiol Rev 2004;17[3]:571.
