HEENT/Neurology (December 2017)
AIR: HEENT/Neurology
Articles:
Spinks et al. “Antibiotics for sore throat (Review).” Cochrane Library 2016.
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
Does reading this article change your practice? If so, how?
7 comments
Spinks et al
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Whether to use abx for strep throat has been a question raised more frequently of late. That’s why we chose this summary. The actual full study is 50+ pages. So we’ll spare you that.
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I think this blog raises valid concerns:
http://rebelem.com/patients-strep-throat-need-treated-antibiotics/
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I think the author conclusions here are reasonable:
“Antibiotics confer relative bene?ts in the treatment of sore throat. However, the absolute bene?ts are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to bene?t. This NNTB may be lower in low-income countries. Antibiotics shorten the duration of symptoms by about 16 hours overall”
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However, the question is: Would you take the antibiotic if you got strep throat? Or if it was your family? We should treat patients with the same level of empathy and care. Personally, I’d take the damn abx.
Sadeghirad et al
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Steroids for sore throat has been used much more frequently just since 5 years ago.
Figure 2 summarizes the evidence well.
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I went to an ACEP talk this year that warned against the use of steroids in strep-negative patients with sore throat, citing anecdotal concerns about masking an alternate more dangerous diagnosis, like retropharyngeal abscess for example. However, the speaker had no evidence to back that up.
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This study seems to show that the new evidence “extends the applicability beyond patients with severe sore throat treated with antibiotics for group A ß haemolytic streptococcus pharyngitis in the emergency department, to a broader range of patients not treated with antibiotics.”
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So I’d be comfortable using it for either viral or strep pharyngitis, assuming we don’t see signs of RPA, or other issues.
Spinks et al.
1. This article is unlikely to change my practice. While this review demonstrates that, on average, antibiotics shorten symptoms by approx 16 hours – a modest benefit with potential for harm from the antibiotics themselves, I would still take them if I was suffering with a nasty sore throat.
2. The study notes that antibiotics help to reduce the severity of symptoms of sore throat and fever by about half which is higher than I would have thought considering that many cases of pharyngitis are caused by viruses and many bacterial infections may be resistent to amoxicillin which is commonly prescribed.
3. I was unaware that antibiotics reduced the rate of rheumatic fever by 2/3 but really who gets rheumatic fever anymore. Is it just no longer prevalent in the US? Where are these benefits seen?
4. The review suggests that the reduction in the incidence of developing glomerulonephritis was difficult to assess and that this would require further evaluation. Additionally, it is not clear to me that antibiotics are definitely responsible for alleviating symtpoms seeing as most people feel better on day 4 even without antibiotics being prescribed. Teasing out the true benefit temporally would seem to be important to me if we are to continue prescribing these medications on a massive scale in an age serious antibiotic resistance.
1 currently use steroids often for treatment of sore throat. I find I most often admin dexamethasone im to provide longer acting anti-inflammatory effects. Prior to starting residency at BMC I definitely used steroids for sore throat more sparingly.
2. I wasn’t aware that people were not regularly prescribing steroids due to a lack of awareness of their efficacy.
3. Useful table which gives me more of an idea about time to resolution of symptoms with steroids.
4. further research comparing different steroids may be warranted as this review largely looked at the use of dexamethasone.
Spinks et al.
1. I tend to prescribe abx for strep + patients who have sore throats because of the impact on duration of symptoms. I think the risk of serious complications of not prescribing are very low in uncomplicated patients. The article makes me feel better about not testing for strep/treating with antibiotics in every case.
2. Nothing debunked, but interesting that rheumatic heart disease is still more common in different parts of the world. I wonder what contributes to this- strain of pathogen? genetics? environmental?
3. I never considered that the use of antibiotics could decrease the rates of the subsequent development of otitis media and sinusitis. This makes sense, but I was surprised this was studied specifically before.
4. Incidence of negative effects related to the use of antibiotics, if antibiotics reduce risk of recurrence
Sadeghirad et al.
1. I will continue to offer steroids to patients with sore throat and this may help me feel more comfortable steering away from abx in some patients, given symptom control seems to be the advantage of both.
2. I am cautious with steroid use especially in diabetic patients, but this article did address adverse effects and I think a burst dose seems generally safe.
3. I learned steroids cannot not only shorten duration of symptoms but also intensity.
4. If differences between po vs. IM/IV steroid effects exist
Cochrane review on Sore throat and Abx (PMID: 17054126)
– It seems to me like using Abx for sore throat is something we can do to help lessen symptoms. After all the article states “duration of pain symptoms by an average of about one day and can reduce the chance of rheumatic fever by more than two-thirds in communities where this complication is common.” However, what was not clear to me is what weight we should assign to the risks associated with using abx (resistance, C-diff, etc). Going forward I will use Abx for moderate to severe cases of sore throat who test negative for strep and all symptomatic pts who test positive.
Corticosteroids for sore throat (PMID: 28931508)
– Oral dexamethasone (Adult 10mg; Kids 0.6 mg/kg (max 10)) were 2x more likely to experience pain relief after 24 hours. ALSO mean time 4.8 hours earlier for those who got steroid to those who didn’t AND 11.1 hours earlier to complete symptoms resolution.
– All ten articles look to have fairly young and healthy patients mean age for all articles was late 20s-mid 30s. Giving steroids to these patients looks to be beneficial but what about older patients with more comorbidities is the risk profile the same? I would pause in giving corticosteroids indiscriminately to that patient population. A few weeks ago Sarah gave a talk on using steroids bursts (while this is a bit different) for COPD exacerbation and those patients had higher risk of developing PEs.