Since I have completed several hospital rotations, I've had the chance to be on the other side of the situation. Now that I understand the reasons for treating vs not treating, I can more properly take care of patients. And I'm a better patient myself whenever I have a sore throat. Let's walk through some of the science behind sore throats and then explore what doctors consider before sending you on your way.
The bacteria that we worry about the most with sore throats is Streptococcus pyogenes, aka Group A Strep. Why do we worry? It's not because the throat infection is particularly bad, or that you cannot recover from the infection on your own. The reason is that throat infections with Group A Strep ("strep throat") can spread from the throat to other areas and cause worse infections. There is a chance that the bacteria can enter the bloodstream and travel to the heart, brain, and joints. This is called acute rheumatic fever. People with rheumatic fever often have a fever and joint pain beginning 1-3 weeks after getting strep throat. The biggest concern from a medical point of view is that the bacteria can infect the heart tissue and cause major problems. You can end up with permanent damage to your heart muscle or valves.
So with all of this scary information about strep throats, why don't we treat every sore throat with antibiotics to prevent rheumatic fever? First of all, sore throats can be caused by viruses as well as bacteria. In fact, most sore throats are viral in nature. The common culprits are adenovirus and the common cold viruses (rhinovirus, coronavirus, parainfluenza). Antibiotics would have absolutely no effect in this case. Secondly, if the sore throat is bacterial, it may not be strep that's causing it. There are a few other bacteria that could be the responsible organism. To be fair, though, Group A Strep is the most common bacteria that causes sore throats.
Lastly, and this is a big point, most of the strep infections will be successfully eradicated by your own body. It's often the case where people with throat infections do not get medical treatment. Their sore throat resolves after several days and they move on with their lives. The reliance on antibiotics has been a recent development in our history, and we did quite well without them, especially with minor infections. It is NOT true that strep throat will always cause rheumatic fever if untreated. The prevalence of rheumatic fever is very low, and is even lower in developed countries like ours. In fact, some countries like England don't bother to test people for Group A Strep because they don't give antibiotics to patients with sore throats unless their mouth is about to implode. You can bet that there are numerous times when patients have strep throat and are not treated, but the amount of rheumatic fever in England is as low as it is here in Canada. This shows how rare it is these days to develop complications from strep throat.
This brings us to how we in Canada treat sore throats (known as acute pharyngitis in the medical community). There is no mystery behind it at all. There are 4 criteria that we look for which may indicate if strep is the culprit. Here they are:
- 1. Fever (Temp >38°C or >100.4°F)
- 2. No cough
- 3. Swollen tonsils with exudate/pus
- 4. Tender lymph node enlargement in the neck
If you have all 4 of these criteria, then you are about 40-60% likely to have strep throat. In this case, the doctor will prescribe penicillin to you right away, and likely get a throat swab to confirm the diagnosis. If, on the other hand, you have a sore throat with a runny nose and cough, no fever, no white stuff coming out of your tonsils, and no swollen lymph nodes, then your infection is almost certainly viral. In this case you would definitely be told to go home and rest. Even if you had one of these criteria, you'd still be sent home sans prescription.
If you have either 2 or 3 of the criteria above, the doctor will likely swab your throat and culture the goop to see if Streptococcus pyogenes will grow. This usually takes 2 days, and often by then the sore throat has resolved. If it hasn't and the culture is positive for strep, then the doctor will prescribe anitbiotics.
So what does this all mean for you, the patient? The next time you get a sore throat and are debating whether to go see a doctor, think about these 4 criteria. If you score a 2 or higher, you may want to go in and get swabbed, or antibiotics if you're lucky enough to get 4 points. But if you score a 0 or 1, stay home and get some chicken soup into you. Wait until tomorrow to see if you get better on your own, or if your score goes up. This may prevent an unnecessary doctor's visit. And more importantly, it will save you from an annoyingly long wait in the waiting room surrounded by other sick people and copies of outdated Readers Digest magazines.
* Click here for an online version of the criteria that you can fill out on your own and find out what to do!
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