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!
3 comments:
Hello Mr. Darwish,
I have had symptoms of strep you described (tonsils with pus & no cough) for approximately a month and a week, including other symptoms of illness that a nurse practicioner I visited over a week ago at my doctor's office did not validate as related to strep when I described them. She said one of my symptoms sounded like I had [a tosilolith], gave me feedback on my throat's hearty post-nasal drip, lack of strepp-y appearance, and ears looking good, and swabbed my throat for a strep culture. I received a call today from my doctor's office - more than one week after my strep swabbing for a culture - telling me that I have "a little" strep, that I should take an Rx that had been called in for me only if I think I need to take it, and that my strep throat would go away on its own.
The pharmacist I visited for my prescription today didn't know why in the nurse practicioner's office's call to me, they would direct me to take the antibiotic only at my discretion since there was a culture showing positive for strep. Why would the caller or practicioner still recommend that I be discretionary with choosing to take antibiotics after a strep-positive culture? I expected that my described 1 month plus of pus-y tonsils would have given the doctor's office enough of a clue that the strep wasn't going away on its own quickly, and that the office wouldn't have left discretion over whether to take antibiotics to a patient who had a strep-positive culture.
Also, I'm still not sure why the culture findings took longer than 2 days to procure, or - especially - 7 days. The doctor's office has been closed only 2 days since my appointment on 7/7 and the strep diagnosis call on 7/15, and did not have the results when I called on 7/9. I haven't ruled out "somebody messed up at the doctor's office between the culture and contacting me." Does a culture containing strep ever take longer than 2 days to grow visible? Can you think of any strep-science related reason for the wait (before I look into this through the receptionists at my doctor's office and prepare to formally complain about this to the accountable office)?
How long does untreated strep throat take to resolve itself on average? I'm taking the antibiotic treatment route with my infection now. I'm curious about what would've happened if I didn't take them and if I did not develop rheumatic fever. Would scarlet fever have been an eventual step to recovery?
Hey Mr Anonymous,
Thanks for your post! It's good to see that people are reading my blog again, and that you are learning things from it. Let me try to answer your questions:
1) It is definitely possible to have the strep culture/swab take longer than 2 days. If the lab received the sample right away and was dying to culture it immediately, and then return the results right away, it would all take 2 days. Sadly, there are often delays in the process. Sometimes the lab will have closed before the sample reached it, meaning the culture wouldn't start until the next day. Sometimes it may take 3 days to culture instead of 2. And then there's the matter of conveying the news back to the doctor. If the clinic was closed for a few days (like the weekend) and you had unlucky timing, you may wait up to a week to get the results. This doesn't make it right, but it's a reality that we can't deny. And more importantly, it often can't be blamed on any one person or group.
2) I'm also unsure what "a little strep" means. The culture is either positive or negative. Maybe if it took longer to culture they may say this, but it's still not appropriate to say. My advice there is that if you have a positive culture and the ability to fill the prescription, then do it. Unless you are morally against antibiotics. They likely told you to do it at your discretion because there was a chance that your body had cleared the infection on its won between the time of the swab and the results.
3) Scarlet fever often affects children moreso than adults, and is apparent early on in the infection. The classic rash begins on the face and neck, and then spreads down to the trunk and arms. It feels a bit like sandpaper. People also get a "strawberry tongue" which sounds like a 5 cent candy to me. You would not develop scarlet fever if you had a sore throat for a while, so it wouldn't be caused by having strep throat for too long. As for rheumatic fever, this is very rare to develop, especially in North America. If they do, the timeline is interesting where they have strep throat for 1-2 weeks, then get better, and THEN rheumatic fever shows up 1-3 weeks later. This may happen whether you get rid of the strep throat or not. So prolonged strep throat may make it slightly more likely but chances are you would have developed it anyway if you were one of the unlucky ones. And remember that some countries don't treat strep throat and have perfectly fine outcomes.
Hopefully that helps to clarify a few things. My advice would be to continue the antibiotics, get better, and then talk with your doctor about your experience. And next time, go see your doctor earlier if you get those symptoms again. Best of luck, Mr Anonymous!
Thank you for your response, Mr. Darwish.
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