There has been a fair amount of twitter buzz about antibiotics for strep throat, and, given the number of pediatric sore throats I have seen this month, it is time to revisit the evidence on this topic.
The major concern for providers is post streptococcal glomerulonephritis, rheumatic fever, and abscess formation. The major concern for parents is the suffering of their child.
Even the IDSA states that PSGN and ARF are extremely rare in the developed world. A recent Cochrane Review reviewed 12,835 cases of sore throat, and found there were too few cases of PSGN to make any conclusions. Mortality from PSGN? 0.028 per 100,000 in North America. (Fun facts, 23.8 per 100,000 in sub-Australia and 4.32 per 100,000 in Mauritius!) As for abscess formation, I was only able to pull up a single retrospective analysis from the UK of 606 cases of peritonsillar abscesses. They conclude that providing an antibiotic on initial evaluation does not significantly reduce the risk of developing an abscess – i.e., providing antibiotics to a sore throat does not reduce the number of PTAs. There is no protective or preventative effect.
So what is the best way to treat the family’s concern?
The pink elephant in the room…
A Cochrane Review of 5352 patients shows penicillin, cephalosporins, and macrolides all have similar efficacy. You have the choices of bicillin x 1 dose, Penicillin x 10 days, the beloved Z-pack, or 5 days of Cefuroxime or Clarithromycin. You have about 12-16 fewer hours of pain with antibiotic treatment. But with that said, a randomized trial of 700 patients, comparing 10 days of antibiotics to 3 days of watchful waiting to no prescription found that 69% of the watchful waiting group did not fill the script. There was no significant differences in duration of illness, missed school or work days, proportion of patients satisfied, and percentage of patients better by Day 3 amongst all three groups. The number needed to harm (diarrhea, abdominal pain, nausea, etc) is ten.
Steroids have been shown to increase the likelihood of resolution of pain at 24 hours by more than three times. The NNT? Under 4. Route does not matter – oral decadron seems as efficacious as IM. Oral dexamethasone daily for three days seems to work faster than a one time dose at resolving pain, but there is no change in return to activity level between one time dosing and 3 day dosing.
As you are wrapping up your discussion with the family, mom drops the bomb that she does not believe in antibiotics, steroids, or vaccinations for that matter. Not coincidentally, she loves yoga, PETA, and natural remedies. What else can you do? In trials that are admitted not of high quality, a few Chinese herbals seem to work reasonably well. Compound dandelion soup was more effective than penicillin, and Yanhouling mixture was found to be more effective than an atomized gentamicin inhalation (the obvious standard of care). Benzocaine lozenges performed superior to placebo for short-term pain control with onset within 20 minutes on average without adverse effects in a study of 165 patients.
The gist: I encourage and offer PO steroids as a one time dose to all sore throats. My facility swabs throats in triage, so I try and do wait & see treatment for positive swabs. I’ll also offer anesthetic lozenges, but not quite willing to discuss Chinese Herbals yet.
- Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America http://cid.oxfordjournals.org/content/55/10/e86.full
- Use of antibiotics for sore throat and incidence of quinsy. PMID: 17244424
- Antibiotics for people with sore throats. PMID: 17054126
- Systemic Review: Estimation of global burden of non-suppurative sequelae of upper respiratory tract infection: rheumatic fever and post-streptococcal glomerulonephritis. PMID: 21371205
- Different antibiotics for group A streptococcal pharyngitis. PMID: 20927734
- Chinese medicinal herbs for sore throat. PMID: 22419300
- Antibiotics for sore throat. PMID: 24190439
- Open randomised trial of prescribing strategies in managing sore throat. PMID: 9116551
- Corticosteroids for pain relief in sore throat: systemic review and meta-analysis. PMID: 19661138
- A randomized clinical trial of oral versus imtramuscular delivery of steroids in acute exudative pharyngitis. PMID: 11772663
- A pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis. PMID: 16732143
- Efficacy of a benzocaine lozenge in the treatment of uncomplicated sore throat. PMID: 22015737