Strep: to treat or not to treat


You might have a pain in your throat

There are a lot of folks in that boat

The very next step

Might be testing for strep

But the score will help with the vote.
Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

The day after Thanksgiving 1997 I hit my personal record for patients seen in a regular clinic day, 63. In other contexts, for example taking call, I’ve attended more, but never in a 9:00AM-Noon, 1:00PM 4:30PM office day.
And not one of those 63 had an appointment when the switchboard opened at 8:30AM.
That November day came in the perfect storm context of coinciding influenza and strep epidemics.
I loved strep epidemics. A simple, curable problem where a minute of history, a minute of physical, a minute of warmth, a minute of education, a simple lab test and a shot of penicillin can relieve great suffering.
We treat strep throat to make the patient feel better, but more importantly, we tell ourselves, to prevent the complications of strep throat: rheumatic heart disease and post-streptococcal glomerulonephritis (kidney failure that follows a strep infection anywhere in the body).
When I started residency, we swabbed every sore throat and sent the culture to a program set up by the family who lost a member to rheumatic heart disease, brought on by strep throat.
In ’85 a widely read article questioned continuing strep treatment in an era of declining rheumatic heart disease.  Much discussion followed, the majority opinion holding that the strains of strep responsible for rheumatic heart disease would start to circulate again. Which, thankfully, has not come to pass.  I heard one doc assert there hadn’t been a single case in the US last year, but couldn’t quote a source.

For decades we’ve had rapid strep tests, which remain in common practice, but in the last year the Centor score, now validated statistically, threatens to make the test obsolete.  The patient gets a point for fever, enlarged nodes in the neck, pus on the tonsils, lack of cough, and/or for age between 3 and 14.  Patients who score 4 or 5 should have antibiotic treatment; under 3 should not.

Those over 44 lose a point; but run a very low risk of rheumatic heart disease.  Treatment in that age group only shortens illness by, on average, 18 hours.

And the post-strep kidney failure?  Treatment does absolutely no good.

But I saw a patient, whose parents gave me permission to write that I’d come up with a perfect score of 5.

I gave penicillin with a clean conscience.

When low scorers come in with sore throats, I discourage testing because a positive result would most likely indicate colonization, where the germs live in the throat without causing problems, rather than infection.

I still do testing if the patient requests penicillin injection, and no injection follows if the test comes up negative.  And I’ll continue the practice till further research demonstrates a reason not to.

Most of the patients with strep throat I saw last week had a sandpaper rash, and very few knew it.

Some things you only find by touching the patient.

 

 

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