You Don’t Need to Come to the ER at 3am for “Strep Throat”

Among the more frustrating ER visits that you will never see on your favorite TV medical drama of choice is that of the 3am visit for possible “Strep Throat”. The sad reality though, is that this is something that we as a medical community have contributed to in a potentially large way. Some people are afraid of Strep because of the supposed connection to Rheumatic fever, while others are just uninformed (putting it nicely) and think that getting that holy prescription for Amoxicillin will make their discomfort go away in a space of hours (which it doesn’t). I guess I should be glad that most of them don’t come in trying to get Percocet to kill the pain (which doesn’t work well in this case either).

Regarding the whole strep and rheumatic fever issue though, I came across an article a few months back that addresses this issue. I will reproduce it at the end of the post for whoever would like to read it, but since it is medical speak to a degree, I thought it might be thoughtful to at least summarize it for those who don’t have the time or medical background to read it.

Basically, the article states that our current understanding that untreated Strep results in Rheumatic fever comes from only one large study that appears to be an anomaly. Two more recent and rigorous medical studies show that there is actually a relatively low risk of Rheumatic fever connected to Strep, and that the number of cases of serious side effects from our overly generous use of antibiotics far outweigh the risks of the limited number of cases of Rheumatic fever in this matter. It recommends against use of antibiotics in this case, but I wonder if the damage is already done? Trying to explain this to the average soccer mom would more likely result in a complaint than a “Oh thank you Doctor for looking out for our best interests!”.

In today’s internet society, too many people come to the doctor looking to get an order filled as opposed to getting an evaluation and medical advice. We keep saying that it is Burger King and we are not here to fill your order, but that message seems to have been missed by Hospital Administration and the general public.

For those who may be interested, here is the article:

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Antibiotics for Strep Do More Harm Than Good
By David H. Newman, MD

Military and civilian medicine have always been intertwined, but nothing compares to the strange tale of Warren Air Force base in the 1940’s. Perched on the high plains outside of Cheyenne, Wyoming, the combat training center was, mysteriously, a bacterial cauldron. For more than a decade virulent strains of group A streptococcus caused unprecedented rates of pharyngitis among the trainees, and history’s worst epidemic of rheumatic fever.

A small cadré of military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory.

Prior to the epidemic at Warren Air Force base there was little interest in ‘strep throat’. During the twenties and thirties in the Unites States, sore throat care focused on diphtheria, “the strangling angel.” The characteristic ‘bull neck’ and the dreaded grey pseudomembrane led to a gruesome, asphyxiating death for thousands of children each year. Comparatively, strep throat was a minor nuisance that often received little more attention than the common cold. But by the 1940s vaccination programs had nearly eradicated diphtheria, and antibiotics were becoming widely available. When the Air Force studies were reported in the early 1950s, they resonated. Rheumatic heart disease was common among adults, making its prevention seem immediate and intuitively important, and antibiotics for a bacterial infection made good sense. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed.

The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely.

At Warren Air Force base only 50-60 recruits were treated to prevent one case. Today, preventing one case would likely require antibiotic treatment for hundreds of thousands of strep throats, making it a mathematical certainty that antibiotics will do more harm than good. For each case of rheumatic fever prevented in modern practice, a few dozen patients either die or suffer near-fatal anaphylaxis, toxic epidermal necrolysis, colitis, or other antibiotic reactions, and many thousands more suffer diarrhea, rashes, and yeast infections.

Fortunately, rheumatic fever has been declining for a century, starting well before the introduction of antibiotics. While strep throat is no less common today, ‘rheumatogenic’ strains have dwindled, leading epidemiologists to conclude that antibiotics have little or nothing to do with rheumatic fever’s disappearance. Changes in hygiene, nutrition, population crowding, access to care, and changes in the bacterium are all felt to be important factors, which explains why the disease is now typically seen most in third world settings.

There are, arguably, other reasons to consider antibiotics for pharyngitis, but the evidence does not rise to support them. The Cochrane group estimates a 16-hour reduction in symptoms with antibiotics, but ibuprofen, acetaminophen, or a single dose of corticosteroids is as good or better, with fewer side effects. And while peritonsillar abscess may be minimally reduced by antibiotics, abscesses typically present primarily rather than after strep throat, and in most cases are easily treated. No studies have shown that antibiotics reduce the transmission of strep or reduce other complications.

The administration of antibiotics for strep throat, endorsed universally by practice guidelines and professional societies, is based exclusively on data from the world’s most concentrated epidemic of rheumatic fever. Using this to guide modern therapy is like administering antibiotics to prevent bubonic plague.

The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.

David H. Newman is the author of
Hippocrates Shadow (Scribner $26)

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23 Responses to You Don’t Need to Come to the ER at 3am for “Strep Throat”

  1. Yazzia says:

    hehe! when can I come to ER? oh i think I have fever that’s so horrible I’m going to die!!! lol! even if people have fever is nuthing to die from or nothing that needs emergency I think…or at least if it’s not 102F it can wait until the day time! i always see on the American movies how people go for no reason almost in the ER!

    • chris says:

      Haha so funny right? Until you can’t sleep or eat or go to work haha silly people for wanting to go to the design stupid us.where do they find you people?

      • chris says:

        This site and comments are completely useless. It provides no solution.and sounds like some lazy hospital worker giving advice and not wanting to do their job. Natural remedies cool. Wtf is that?

  2. Sabra says:

    Anytime I have an excuse to not give an antibiotic, I’m there. I suck at remembering to take/give them, and I know that’s a bad thing. My ex-husband is usually pretty cool about it, but his parents think I’m a horrible mother if I don’t drop everything and run to the doctor for each and every sniffle. (They don’t have to pay co-pays, though! They’re both on Tricare.)

    • Tunde says:

      Agree Sabra, first of all, there is too much miss use of the antibiotics by people who are requesting , and doctors who just want to get the parents or patients off their back, and the people who think antibiotic cures all.

      No wonder we have all these antibiotic resistence bugs like MRSA.
      Also, with no co pay or medicaid people tend to run to the doctor’s office or ER b/c they don’t have to pay. Little that they know while they waiting they might just pick up some other sickness from there.

      As for your ex in laws they need get a life why do you even care lol. You are the mother and mothers knows best…at least most cases, and seeing your writting i am sure you are a very capable mom.

  3. Sapphire says:

    I knew somebody who had Strep throat and they were in misery. They were up at night gagging and having trouble trying to swallow. All most people want is relief from their symptoms so they can sleep at night. If doctors are not going to prescribe antibiotics what will they suggest the person do just suffer with it?

    • Sabra says:

      Put quite simply, antibiotics do nothing for pain.

      • Brenna says:

        No, but they do speed up the healing process, therefore ending pain sooner than just toughing it out.

        I understand where you (the author of the post) are coming from, not wanting to prescribe antibiotics unnecessarily, but I think it’s unfair to get down on people who aren’t up to date on the latest research. While I don’t think I would take my kids to the ER, I did take one to Urgent Care (it was a Sunday) and the other one to the pediatrician, for Strep throat. My point is being, that is what most people know: if your kid has a fever and a very sore throat, they need a strep test and, if positive, antibiotics. I have never requested antibiotics, for myself or my children. This is only a second antibiotics prescription for both of my older kids. I think it’s cruel to let kids suffer for a week or more with strep when they can be feeling better in 24 hours with antibiotics.

      • ER Doc says:

        Thank you for your comment Brenna. The point that was being made in the article was that antibiotics have in a number of cases done a lot of harm and to be judicious in using them. We are at a very critical point in history with several antibiotics no longer being useful for such common things as urinary tract infections, strep throat and skin infections (cellulitis). This has happened due to careless use of antibiotics. I never suggested anywhere that children, or adults for that matter, should be made to suffer. As a parent myself, I have been able to help my own children through most of these types of infections without antibiotics. The other issue that is important to consider is the increasing rate of strep carriers – people who will always be positive for strep. That is why it is not always as simple as getting the test and if positive giving the antibiotics. Lastly, most antibiotics scientifically will not do anything for such an infection for the first 48 hours. That is why we keep children who are receiving antibiotics out of school or daycare for at least 2 days when we start them on antibiotics if needed. The fact that some people do feel better in less than 48 hours would be related to placebo effect in most cases since the drug has not reached adequate levels in the bloodstream by that time.

        Once again, I hope that you will reread the post and see that I am not expecting the average non-medical person to keep abreast of medical research. I stated clearly that this behavior in patients is one driven by our own actions as medical practitioners. I would hope that from the tone of many of my posts you would notice that I try to always give patients benefit of the doubt and not to be judgmental with them. I hope this explanation will clarify for you some of the thought process we deal with in any case and hope that if I offended you that you accept my apology.

    • ER Doc says:

      Hello Sapphire and thank you for your comment. I believe Sabra beat me to the answer and stated it well, that antibiotics don’t help pain – at least not for 2-3 days. In the majority of cases of sore throat, bacterial or viral, the pain will already be better in 2-3 days. When people come to get help in the ER for their pain I recommend for them what I personally use and what I give to my own family for throat pain – Sucrets lozenges and warm liquids. As I had pointed out in an earlier post, we have become accustomed as a society to expecting immediate gratification in many areas, and medicine is one of those areas. Sadly, medical science has not yet reached the point where there are medicines that kill throat pain 100%. Even medicines like Percocet and Vicodin only dull the person so they can tolerate the pain better, but they are then so dull that they can do nothing else anyways. I am a human being like everyone else and I get my fair share of sore throats dealing with patients breathing and coughing on me all through flu season. This is how I manage it myself and how I encourage others to do it. I hope this helps clear the issue for you.

  4. WarmSocks says:

    I’m a little confused. I thought that “emergency” meant the person might die without prompt help (and might die anyway since the problem is so bad). Who dies from a sore throat?

    I’ve always heard that if a sore throat lasts more than a week, you should see your PCP to make sure it’s not strep. With the new research saying antibiotics aren’t necessary for strep, I would want my doctor to tell me that (but now he doesn’t have to – thank you). Is there ever a reason to see a doctor about a sore throat? Drive one hour to see the doctor, 20 minutes in his office, 45 minutes at the pharmacy, another hour to drive home… I’d rather just stay home and save the time and money. Hot lemonade is my sore throat treatment of choice.

  5. Erica says:

    So true. ‘Round here, we joke about needing to come up with a “Patient Self Order Form” and a “Google-Assisted Self-Diagnosis Form” – would save us all a lot of time and heartache for those folks who come in with a predetermined idea of what they hope to accomplish in the visit. And in fairness, I don’t think you were insinuating that non-medical people should have any specialized medical knowledge… But as I recall, in the “olden days,” (prior to the Internet) people actually trusted their doctors to do right by them, rather than second-guessing and criticizing what’s still good medicine.

    • michele says:

      Actually I think it is vital for a patient to be his own advocate when it comes to healthcare. There are a lot of doctors out there who don’t know what they are doing and don’t really is very helpful for the patient to have some idea what they want from their doctor or the ER before they get there. Doctors are only human so I think it is prudent to not trust them blindly.

  6. Channary says:

    ER Doc, if you’re still out there I have a question.

    I went to the doctor over a week ago with a swollen painful throat and I had a fever. I was prescribed Augmentin originally, which helped for a few days and then lost effectiveness entirely. At that point my strep test came back positive, but for Strep C, not Strep A. By the end of last week I was running a constant fever (between 101F and 103F). My tonsils were “kissing” and covered in pus. Understandably, I could not swallow. I could not sleep because of the pain. I could not eat or drink from the pain and swelling and began vomiting on Sunday night. My father, a physician himself, seriously considered taking me to the ER because I could not force fluids. Upon hearing that I pulled it together and downed two glasses of water and tried to sleep. I saw my primary doc the next day (ysterday) and was prescribed Prednisone for the swelling and Percocets for the pain. I am no longer taking the Augmentin as it was ineffective.

    So I have two questions:

    (1) Should I have gone to the hospital Sunday night? If I had gone, what would have been done?

    (2) Should I not have been prescribed Percocets? I agree with you that they do not work well in the case of strep throat. The pain is still there, it is definitely dulled. I also find myself calmer, like my brain ignores the pain so that I can eat and drink and sleep.

    (3) Is my case a testament to the opinion that antibiotics should not be prescribed for strep? All I got out of the antibiotic this time was two days of relief and then a terrible yeast infection.

    Any advice or opinions would be much appreciated! You are easily the most well-spoken blogger I’ve ever read.

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  9. a personssss says:

    I see all these comments about taking the antibiotics.. but I went to the ER not bc I had sore throat but because I developed pain behind my belly button in fear of my appendix or gallbladder or something Stevere. Later finding it was a “side effect” of strep … I was told to take an antibiotic. So am I dumb for trusting this Dr? I know I’m late to this article
    I’m 17 year old guy

  10. Brain Avellar says:

    When it comes to sore throat, the two things that help me a lot are sodium ascorbate and oral lidocaine to control the pain. ‘*.”`

    View the most up to date piece of writing at our new web site

  11. Andrew says:

    So when should i go to the doc for strep? Ive been calling around to various clinics to try to get an appointment but most are booked for weeks. Ive had strep over 6 times so i know what it is. swollen glands, white stuff on the tonsils, swollen tonsils, was very achey and sore yesterday but today its a little better and i can actually move. head isnt as hot and im not as sweaty. is that a sign of getting better and no need for a doc visit?

  12. Mag says:

    Okay, I completely agree for the most part. However, when is it appropriate to go to the ER for strep? I ignored my pain, and let my body heal itself with the whole “chicken soup” thing, but I began spitting up alarming quantities of blood and puss. My tonsils looked like they were covering the opening to my throat. What does someone do in this case?

  13. Hilario Galban says:

    There are many ways of helping the body in dealing with infections. Home remedies for strep throat are various and they include many aspects: diet, natural antiseptics, natural analgesics or natural antibacterial cures. Used appropriately, home remedies for strep throat can speed up the process of healing by fighting bacteria and by stimulating the immune system of the body.;

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  14. Jing says:

    It’s good to know about this.Thank you for sharing.

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