abx for strep pharyngitis?

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It is great that a couple of academic physicians in Emergency Medicine feel that there is low yield to treating strep throat with antibiotics. However, no one else in the rest of medicine (cardiology, ID, peds…), or the public, feels this way. Therefore, strep throat is treated with antibiotics.

Do you really want the parent of a child with rheumatic fever +/- complications to come after you? It's just not worth it.

Have you ever seen a case of Tetanus in the US? Do we give Tetanus shots?
 
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Is there anything antibiotics actually work for? Maybe we should get rid of them all together.

They don't help URIs.

They don't help sinusitis.

They don't help bronchitis.

They don't help pharyngitis.

They don't help abscesses.

What's the NNT for UTIs, meningitis, PNA, cellulitis etc?

Heck, these guys argue you shouldn't treat old folks with UTIs unless they have symptoms. Of course, they don't mention what symptoms they're talking about.

http://www.choosingwisely.org/docto...for-urinary-tract-infections-in-older-people/
 
The White Coat Investor said:
Is there anything antibiotics actually work for? Maybe we should get rid of them all together.

They don't help URIs.

They don't help sinusitis.

They don't help bronchitis.

They don't help pharyngitis.

They don't help abscesses.

What's the NNT for UTIs, meningitis, PNA, cellulitis etc?

Heck, these guys argue you shouldn't treat old folks with UTIs unless they have symptoms. Of course, they don't mention what symptoms they're talking about.

http://www.choosingwisely.org/docto...for-urinary-tract-infections-in-older-people/
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Jeez....you should know better, WCI. Their number one use, is for viruses! They ward off evil "virus bugs" after about 5-7 days. And they create stars, that is five STAR patient satisfaction scores.

Don't you know, Pen "VK" stands for "virus killer"?

Geez, man....get with the program. smh
 
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70% of pharyngitides are caused by viruses. The CDC stopped tracking RHD since the incidence is ~1/1,000,000. Besides, NSAIDs and steroids do more to make you feel better.

Even at the height of the WAFB strep epidemic, the NNT for Abx to prevent one case of rheumatic disease was 80. No doubt - they did a lot of really cool science. But nowadays you're going to cause thousands of cases of diarrhea, candidiasis, and anaphylaxis in order to prevent that one case of clinical rheumatic heart disease.
 
Hair Police said:
70% of pharyngitides are caused by viruses. The CDC stopped tracking RHD since the incidence is ~1/1,000,000. Besides, NSAIDs and steroids do more to make you feel better.

Even at the height of the WAFB strep epidemic, the NNT for Abx to prevent one case of rheumatic disease was 80. No doubt - they did a lot of really cool science. But nowadays you're going to cause thousands of cases of diarrhea, candidiasis, and anaphylaxis in order to prevent that one case of clinical rheumatic heart disease.
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And even the 30% that is bacteria doesn't necessarily NEED or even benefit from abx. Our body can kill bacteria too...if I remember anything from med school. It's a small subset of that 30% in really select individuals that need/would benefit from abx.
 
I don't test for strep. Antibiotics are of no use. I tell every single patient that it's a viral pharyngitis and that I wouldn't recommend antibiotics. Then I discharged them home.
 
VA Hopeful Dr said:
UpToDate (the only resource I have the will to use while eating breakfast) tells me that antibiotics, especially early on, can reduce symptom duration by about 2 days. Thoughts on that?
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It's more like 12 hours, maybe 24.
 
The irony? some of the biggest proven uses of antibiotics that I know of are for pre-op patients, pt's with variceal bleeding, pt's with COPD, none of which are active bacterial illnesses.
 
Shared decision making. I make sure they know that the science for benefit *here* in the states is incredibly low, orders of magnitude lower than the harms. If they demand them, so be it. People eat McDonald's too, I don't knock the food out of their hand.
If they're from an area with rheumatic strains, then all bets are off.
 
Dr.McNinja said:
Shared decision making. I make sure they know that the science for benefit *here* in the states is incredibly low, orders of magnitude lower than the harms. If they demand them, so be it. People eat McDonald's too, I don't knock the food out of their hand.
If they're from an area with rheumatic strains, then all bets are off.
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Not to be overly lazy, but do you know the regions with RF strep strains?
 
Rendar5 said:
The irony? some of the biggest proven uses of antibiotics that I know of are for pre-op patients, pt's with variceal bleeding, pt's with COPD, none of which are active bacterial illnesses.
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Antibiotics "proven" for COPD? In what respect? I never put COPD patients on antibiotics unless they have pneumonia, UTI or other likely bacterial source.
 
TooMuchResearch said:
Not to be overly lazy, but do you know the regions with RF strep strains?
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http://emedicine.medscape.com/article/236582-overview#a0199
ARF is predominantly a disease of developing countries and is concentrated in areas of deprivation and crowding. It is rampant in the Middle East, in sub-Saharan Africa, in the Indian subcontinent, in certain areas of South America, in Polynesia, and among the indigenous populations of Australia and New Zealand. Although a genetic predisposition to ARF clearly exists,[1] the disease does not seem to have a major racial predisposition, as it was once common in the United States and Europe and seems to decline in any locale where living conditions improve.
Also: http://cid.oxfordjournals.org/content/33/6/806.long
 
ABx for COPD - doxycyline is what I generally use (cheap). Azithro is an alternate.

Strep/RHD - IIRC, RHD is #1 or 2 cause of CHF in the developing world.
 
This statement in the conclusion says it all: "Finally, some studies used clinical criteria to rule out pneumonia, instead of using x-ray evaluation."

If you're not going to rule-out pneumonia with a CXR, then saying that antibiotics are effective in outpatient COPD WITHOUT pneumonia is difficult.
 
Don't Podcast Yourself To Death

Antibiotics for copd never was a big stretch for me. They're a group with a serious morbidity, they're very prone to pneumonia, and they have so much mucous production I can easily see there being subclinical bacterial involvement there, without it necessarily ever forming detectable consolidation on a CXR, or ever being demonstrable on a pure RCT done with gold-standard bronchalveolar lavage technique.

For ----s sake, can we not ever do anything that makes sense anymore, or use clinical judgement, ever, without first bowing at the alter of EBM, which itself is far, far from being pure of corruption, drug company influence, and numerous types of bias including publication bias and other severe flaws?

You became a doctor to treat sick people, and amongst all the straphangers wandering into your ED who aren't really sick, you've finally got a documented bacterial infection with symptoms in front of you? Treat it.

Treat it!

I don't care what the NNT/NTHs are. Those analyses are not statistically perfect in any sense of the word, any more than are the papers they were derived from. Pretty soon you're seeing mastoiditis from the untreated otitis (was a real entity before antibiotics), more peritonsillar abscesses (from untreated bacterial tonsillitis) and so on.

Yes, there's a push to reduce unnecessary testing and over treatment and we should be cognizant of that. I'm all for the scientific method and questioning dogma, but medicine will never be a perfect science like nuclear physics or mathematics. Argue all day long and podcast yourself to death, but some things ...just...make...sense...

Do them, for God's sake.
 
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Birdstrike said:
Don't Podcast Yourself To Death

Antibiotics for copd never was a big stretch for me. They're a group with a serious morbidity, they're very prone to pneumonia, and they have so much mucous production I can easily see there being subclinical bacterial involvement there, without it necessarily ever forming detectable consolidation on a CXR, or ever being demonstrable on a pure RCT done with gold-standard bronchalveolar lavage technique.

For ----s sake, can we not ever do anything that makes sense anymore, or use clinical judgement, ever, without first bowing at the alter of EBM, which itself is far, far from being pure of corruption, drug company influence, and numerous types of bias including publication bias and other severe flaws?

You became a doctor to treat sick people, and amongst all the straphangers wandering into your ED who aren't really sick, you've finally got a documented bacterial infection with symptoms in front of you? Treat it.

Treat it!

I don't care what the NNT/NTHs are. Those analyses are not statistically perfect in any sense of the word, any more than are the papers they were derived from. Pretty soon you're seeing mastoiditis from the untreated otitis (was a real entity before antibiotics), more peritonsillar abscesses (from untreated bacterial tonsillitis) and so on.

Yes, there's a push to reduce unnecessary testing and over treatment and we should be cognizant of that. I'm all for the scientific method and questioning dogma, but medicine will never be a perfect science like nuclear physics or mathematics. Argue all day long and podcast yourself to death, but some things ...just...make...sense...

Do them, for God's sake.
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I just did a lit search and there are ZERO double-blinded studies on the outcomes of making sense.

ZERO
 
GeneralVeers said:
This statement in the conclusion says it all: "Finally, some studies used clinical criteria to rule out pneumonia, instead of using x-ray evaluation."

If you're not going to rule-out pneumonia with a CXR, then saying that antibiotics are effective in outpatient COPD WITHOUT pneumonia is difficult.
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If I am seeing you and you walk in with diminished lung sounds +/- wheezing and you aren't clearly in that otherwise healthy teenage demographic with a documented history of asthma exacerbation ... you are getting a chest xray. If your chest xray is clear, you have a normal WBC count, you have a history of smoking/COPD, and your symptoms are.improved after a breathing treatment(s) and you've gotten solumedrol you go home without ABX.
 
Birdstrike said:
Don't Podcast Yourself To Death

Antibiotics for copd never was a big stretch for me. They're a group with a serious morbidity, they're very prone to pneumonia, and they have so much mucous production I can easily see there being subclinical bacterial involvement there, without it necessarily ever forming detectable consolidation on a CXR, or ever being demonstrable on a pure RCT done with gold-standard bronchalveolar lavage technique.

For ----s sake, can we not ever do anything that makes sense anymore, or use clinical judgement, ever, without first bowing at the alter of EBM, which itself is far, far from being pure of corruption, drug company influence, and numerous types of bias including publication bias and other severe flaws?

You became a doctor to treat sick people, and amongst all the straphangers wandering into your ED who aren't really sick, you've finally got a documented bacterial infection with symptoms in front of you? Treat it.

Treat it!

I don't care what the NNT/NTHs are. Those analyses are not statistically perfect in any sense of the word, any more than are the papers they were derived from. Pretty soon you're seeing mastoiditis from the untreated otitis (was a real entity before antibiotics), more peritonsillar abscesses (from untreated bacterial tonsillitis) and so on.

Yes, there's a push to reduce unnecessary testing and over treatment and we should be cognizant of that. I'm all for the scientific method and questioning dogma, but medicine will never be a perfect science like nuclear physics or mathematics. Argue all day long and podcast yourself to death, but some things ...just...make...sense...

Do them, for God's sake.
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To be fair... You really won't be seeing mastoiditis upticking any time soon. That's a benefit that's been pretty clearly linked to vaccine use changing the otitis media flora. The remaining bacteria have never shown any real risk of maatoiditis or hearing loss if untreated except in certain at risk populations (and even that's more physiology theory over demonstrated risk).

A kid who will get mastoiditis will walk in the room with it right off the bat, or so the teaching goes.
 
and does group f strep even have a relationship to badness outcomes such as the kidney/heart that tenuously supports tx w/ abx for group a?
 
dotcb said:
It is great that a couple of academic physicians in Emergency Medicine feel that there is low yield to treating strep throat with antibiotics. However, no one else in the rest of medicine (cardiology, ID, peds…), or the public, feels this way. Therefore, strep throat is treated with antibiotics.

Do you really want the parent of a child with rheumatic fever +/- complications to come after you? It's just not worth it.

Have you ever seen a case of Tetanus in the US? Do we give Tetanus shots?
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Yes to tetanus.
 
oldanddone said:
and does group f strep even have a relationship to badness outcomes such as the kidney/heart that tenuously supports tx w/ abx for group a?
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Show me any data that supports ABx for kidney benefit. Your own board answer is that ABx doesn't prevent PSGN. Thus, no.
ABx also don't prevent suppurative complications. They aren't needed for simple abscesses that are I&D'd.
They aren't the end all be all, and using them for things that don't need it is why when we DO need them, they don't work.
 
Whatever, All my strep throats and otitis medias are going on Teixobactin from now on. Nothing could go wrong with that strategy. As Birdstrike says: if you got it, kill it.

My pt sat scores are going to be through the roof!
 
Dr.McNinja said:
Show me any data that supports ABx for kidney benefit. Your own board answer is that ABx doesn't prevent PSGN. Thus, no.
ABx also don't prevent suppurative complications. They aren't needed for simple abscesses that are I&D'd.
They aren't the end all be all, and using them for things that don't need it is why when we DO need them, they don't work.
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David Newman has a great SmartEM podcast about this topic. Per his review of the literature, antibiotics may prevent suppurative complications (specifically PTAs) but the benefit of preventing this relatively rare, treatable complication is massively outweighed by all of the harms associated with giving abx. Also gives some interesting historical tidbits about the data regarding rheumatic heart disease almost all coming out of one military base and the surrounding area post-WWII. Find it here: http://smartem.org/podcasts/treatment-acute-pharyngitis -- His stuff is long and he can definitely get on an EBM soapbox (that I'm sympathetic to, but the choir can only get preached to so much), but I love it and wish he'd put them out more frequently.
 
For all my sore throats that are clearly not strep, I use the following speech:

"Well, the good news here is that this is very unlikely to be strep throat. The better news here is: I can make you feel better and avoid the nasty side-effects of antibiotics. Remember: antibiotics have a dark side, too... diarrhea, allergic reactions, resistance. Let do the smart thing here.

Then, offer low-dose steroids and viscous lidocaine FTW.

I seriously never, ever give abx for sore throat that not ZOMG strep.
 
You guys are really overthinking this. Strep is easily treated with Pcn which is a cheap drug that doesn't have a big resistance problem. Is there really a huge problem with PCN-resistant Strep? No. Have I seen PTA's and sepsis from strep throat. Yep. We even had a 28 yo Tetatnus pt a month ago (who was 7 years s/p last shot). If my kid had strep, would I treat it? Yes--one less day of strep is worth a few days of cheap Amoxicillin. What's the NNT for abx in CAP? Who knows, but if you don't give it, you're going to have a bad outcome you can't justify and you're overthinking things. And your patients are going to hate you.

People want something to feel better, even if it is a placebo, which is why I write URI's for OTC cough medicine. They want something, which is why they are in the ER. I treat UTI's in old people, b/c I see Uroseptic elderly every other day. The whole "choose wisely" campaign is written by a bunch of academics who work clinically once a week and whose residents see their patients. They don't have hospital admin breathing down their necks for PG scores, and they certainly don't have any standing ground the second something goes bad (and something will eventually go bad if you see enough patients--you don't have a leg to stand on if you have a kid who gets sick from strep and you didn't write abx). Trust me--don't overthink things. Common sense>>EBM and assinine guidelines. Even the most contrarian of all ED Docs, Dr Jerome Hoffmann from UCLA, said in a lecture he gives abx to URI's if parents dig their heals and push for it. You're fighting a losing battle. Rapid strep takes 30 min, and it makes parents feel better. All it takes to win the good graces of a mother is testing for strep (or empirically treating). It's either "good news--not strep, supportive care", or "it is strep, but good news, we can easily treat this w/ abx." Nobody in the real world gives a crap about the NNT or the incidence of Rheumatic Fever--they just want to feel better, and if you have a means of doing it (even if it is just slightly better than placebo) more power to you. Community Medicine 101. If you have a problem with that, stick to acadmic sites (which are more and more becoming community-like as corporate med swallows hospital systems whole).
 
sum dude said:
You guys are really overthinking this. Strep is easily treated with Pcn which is a cheap drug that doesn't have a big resistance problem. Is there really a huge problem with PCN-resistant Strep? No. Have I seen PTA's and sepsis from strep throat. Yep. We even had a 28 yo Tetatnus pt a month ago (who was 7 years s/p last shot). If my kid had strep, would I treat it? Yes--one less day of strep is worth a few days of cheap Amoxicillin. What's the NNT for abx in CAP? Who knows, but if you don't give it, you're going to have a bad outcome you can't justify and you're overthinking things. And your patients are going to hate you.

People want something to feel better, even if it is a placebo, which is why I write URI's for OTC cough medicine. They want something, which is why they are in the ER. I treat UTI's in old people, b/c I see Uroseptic elderly every other day. The whole "choose wisely" campaign is written by a bunch of academics who work clinically once a week and whose residents see their patients. They don't have hospital admin breathing down their necks for PG scores, and they certainly don't have any standing ground the second something goes bad (and something will eventually go bad if you see enough patients--you don't have a leg to stand on if you have a kid who gets sick from strep and you didn't write abx). Trust me--don't overthink things. Common sense>>EBM and assinine guidelines. Even the most contrarian of all ED Docs, Dr Jerome Hoffmann from UCLA, said in a lecture he gives abx to URI's if parents dig their heals and push for it. You're fighting a losing battle. Rapid strep takes 30 min, and it makes parents feel better. All it takes to win the good graces of a mother is testing for strep (or empirically treating). It's either "good news--not strep, supportive care", or "it is strep, but good news, we can easily treat this w/ abx." Nobody in the real world gives a crap about the NNT or the incidence of Rheumatic Fever--they just want to feel better, and if you have a means of doing it (even if it is just slightly better than placebo) more power to you. Community Medicine 101. If you have a problem with that, stick to acadmic sites (which are more and more becoming community-like as corporate med swallows hospital systems whole).
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:applause:
 
sum dude said:
You guys are really overthinking this. Strep is easily treated with Pcn which is a cheap drug that doesn't have a big resistance problem. Is there really a huge problem with PCN-resistant Strep? No. Have I seen PTA's and sepsis from strep throat. Yep. We even had a 28 yo Tetatnus pt a month ago (who was 7 years s/p last shot). If my kid had strep, would I treat it? Yes--one less day of strep is worth a few days of cheap Amoxicillin. What's the NNT for abx in CAP? Who knows, but if you don't give it, you're going to have a bad outcome you can't justify and you're overthinking things. And your patients are going to hate you.

People want something to feel better, even if it is a placebo, which is why I write URI's for OTC cough medicine. They want something, which is why they are in the ER. I treat UTI's in old people, b/c I see Uroseptic elderly every other day. The whole "choose wisely" campaign is written by a bunch of academics who work clinically once a week and whose residents see their patients. They don't have hospital admin breathing down their necks for PG scores, and they certainly don't have any standing ground the second something goes bad (and something will eventually go bad if you see enough patients--you don't have a leg to stand on if you have a kid who gets sick from strep and you didn't write abx). Trust me--don't overthink things. Common sense>>EBM and assinine guidelines. Even the most contrarian of all ED Docs, Dr Jerome Hoffmann from UCLA, said in a lecture he gives abx to URI's if parents dig their heals and push for it. You're fighting a losing battle. Rapid strep takes 30 min, and it makes parents feel better. All it takes to win the good graces of a mother is testing for strep (or empirically treating). It's either "good news--not strep, supportive care", or "it is strep, but good news, we can easily treat this w/ abx." Nobody in the real world gives a crap about the NNT or the incidence of Rheumatic Fever--they just want to feel better, and if you have a means of doing it (even if it is just slightly better than placebo) more power to you. Community Medicine 101. If you have a problem with that, stick to acadmic sites (which are more and more becoming community-like as corporate med swallows hospital systems whole).
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I don't think its just an academic argument. If you're harming more people with anaphylaxis than you're helping, then you're practicing bad medicine. A lot of what we do is bad medicine and will require a massive culture change.
 
sum dude said:
Nobody in the real world gives a crap about the NNT or the incidence of Rheumatic Fever--they just want to feel better, and if you have a means of doing it (even if it is just slightly better than placebo) more power to you. Community Medicine 101. If you have a problem with that, stick to acadmic sites (which are more and more becoming community-like as corporate med swallows hospital systems whole).
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Community Medicine is why there's a measles outbreak from Disneyland. While we shouldn't patronize our patients, we shouldn't do everything they want either. There's a reason we had to go to 11+ years of school, and it's to make the hard choices, not the easy ones.
 
sum dude said:
You guys are really overthinking this. Strep is easily treated with Pcn which is a cheap drug that doesn't have a big resistance problem. Is there really a huge problem with PCN-resistant Strep? No. Have I seen PTA's and sepsis from strep throat. Yep. We even had a 28 yo Tetatnus pt a month ago (who was 7 years s/p last shot). If my kid had strep, would I treat it? Yes--one less day of strep is worth a few days of cheap Amoxicillin. What's the NNT for abx in CAP? Who knows, but if you don't give it, you're going to have a bad outcome you can't justify and you're overthinking things. And your patients are going to hate you.

People want something to feel better, even if it is a placebo, which is why I write URI's for OTC cough medicine. They want something, which is why they are in the ER. I treat UTI's in old people, b/c I see Uroseptic elderly every other day. The whole "choose wisely" campaign is written by a bunch of academics who work clinically once a week and whose residents see their patients. They don't have hospital admin breathing down their necks for PG scores, and they certainly don't have any standing ground the second something goes bad (and something will eventually go bad if you see enough patients--you don't have a leg to stand on if you have a kid who gets sick from strep and you didn't write abx). Trust me--don't overthink things. Common sense>>EBM and assinine guidelines. Even the most contrarian of all ED Docs, Dr Jerome Hoffmann from UCLA, said in a lecture he gives abx to URI's if parents dig their heals and push for it. You're fighting a losing battle. Rapid strep takes 30 min, and it makes parents feel better. All it takes to win the good graces of a mother is testing for strep (or empirically treating). It's either "good news--not strep, supportive care", or "it is strep, but good news, we can easily treat this w/ abx." Nobody in the real world gives a crap about the NNT or the incidence of Rheumatic Fever--they just want to feel better, and if you have a means of doing it (even if it is just slightly better than placebo) more power to you. Community Medicine 101. If you have a problem with that, stick to acadmic sites (which are more and more becoming community-like as corporate med swallows hospital systems whole).
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I.e., it doesn't matter if it's the right thing to do, if the alternative is easier and makes more friends?

Agree with needed culture change. Also agree all the incentives in our system are built-in to resist it.
 
TimesNewRoman said:
I don't think its just an academic argument. If you're harming more people with anaphylaxis than you're helping, then you're practicing bad medicine. A lot of what we do is bad medicine and will require a massive culture change.
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Nnt 28 for PTA. Which is an OR procedure for kid. Potential for sepsis. Angry parents. All a much higher risk than analphylaxis in patient. You guys are fighting a losing battle. I'm not advocating abx for viral infections, and I personally love Newman's site. But if you don't give abx for an easily treatable BACTERIAL disease (that's been standard of care for 60 years), I guarantee you will eventually have a bad outcome you cannot justify, not to your director/hospital/or a jury. But hey, good luck selling the jury with that phantom saving the world from analphylaxis crusade.
 
"But hey, good luck selling the jury with that phantom saving the world from analphylaxis crusade."

It's hardly a phantom when you have to cut into their throat.
 
Every single one of you has caved before. Every single one, has at some point caved to what was not the "ideal in a perfect EBM vacuum" thing to do. You probably do it regularly, more than you think (or admit), not to mention what is "the perfect thing to do" according to some EBM podcast today, may the wrong thing next year, or vice versa.

I'm not buying it. Y'all are irradiating the crap out of people, prescribing antibiotics because "that ear looks a little too red" or admitting people to cover your butt, that could go home, by some "EBM ideal," or doing things you might not do, due to Press-Ganey threats by your admin. And some of those that get admitted get a catheter and a uti, or fall off their hospital bed and get a fracture or get a nosocomial pneumonia. You're pan-scanning traumas that don't always have not a single clinically relevant finding, that could've gotten less. Uh-huh. None of you are "pure of EBM heart." Not one.
 
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Birdstrike said:
Every single one of you has caved before. Every single one, has at some point caved to what was not the "ideal in a perfect EBM vacuum" thing to do. You probably do it regularly, more than you think (or admit), not to mention what is "the perfect thing to do" according to some EBM podcast today, may the wrong thing next year, or vice versa.

I'm not buying it. Y'all are irradiating the crap out of people, prescribing antibiotics because "that ear looks a little too red" or admitting people to cover your butt, that could go home, by some "EBM ideal," or doing things you might not do, due to Press-Ganey threats by your admin. And some of those that get admitted get a catheter and a uti, or fall off their hospital bed and get a fracture or get a nosocomial pneumonia. You're pan-scanning traumas that don't always have not a single clinically relevant finding, that could've gotten less. Uh-huh. None of you are "pure of EBM heart." Not one.
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I like this. A lot.

There's a cognitive disconnect with the overreliance on EBM in clinical medicine. EBM is the forest, and aggregated data (no matter how well designed the study) have an inherent normalization bias.

Our patients are the trees. They often fall outside the EBM umbrellas (there's a reason we report CI and alpha values - outliers always exist) - and sometimes we choose to do things that population-based data don't support... even after excluding the MedMal argument.

EBM is all fine & dandy, and I support its development; however, I practice reality-based medicine and sometimes this runs afoul of what the "experts" say but provides the level of patient care I believe necessary.

This is what separates us from Watson - the ability to see the intangibles and know when to deviate from the "rules."

Cheers!
-d
 
Dr.McNinja said:
Community Medicine is why there's a measles outbreak from Disneyland.
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Flesh this one out a bit for me, if you please. How does "neo hippie crunchy idiot parent that doesn't get their kids immunized" equal "community medicine"? What I know is docs going blue in the face exhorting vaccines, and doltish, misinformed parents saying "NO!"
 
I like how you all are acting like people who write for abx for strep are going against standard of care. If you don't write for abx, you guys are naked in the breeze. It's not enabling by following textbook care for strep. Enabling is writing abx for a virus. I've never had an analphylaxis from amox I've written in ED on a kid, but seen plenty of PTA's and even a few strep sepsis kids. Give him 1st dose in ER, or give Bicillin if you are worried about reaction.
If you are worried about analphylaxis, you are going have a tough time writing any meds outside of albuterol. Seriously, how many meds on patients you need are actually necessary? They all cary risk of analphylaxis.
Feel free to stay on your EBM high horse, but the EBM nazi's are the same ones who led the charge to put central lines in stable patients with lactics of 4 (since overturned) and blood cultures on everyone. I'm all for physician and patient autonomy--if you convince someone abx aren't worth it, more power to ya.
 
Birdstrike said:
Every single one of you has caved before. Every single one, has at some point caved to what was not the "ideal in a perfect EBM vacuum" thing to do. You probably do it regularly, more than you think (or admit), not to mention what is "the perfect thing to do" according to some EBM podcast today, may the wrong thing next year, or vice versa.

I'm not buying it. Y'all are irradiating the crap out of people, prescribing antibiotics because "that ear looks a little too red" or admitting people to cover your butt, that could go home, by some "EBM ideal," or doing things you might not do, due to Press-Ganey threats by your admin. And some of those that get admitted get a catheter and a uti, or fall off their hospital bed and get a fracture or get a nosocomial pneumonia. You're pan-scanning traumas that don't always have not a single clinically relevant finding, that could've gotten less. Uh-huh. None of you are "pure of EBM heart." Not one.
Click to expand...

What are you going for here? If you don't practice EBM *every*single*time*, you're a hypocrite for doing it at all? Sometimes there's gray areas, sometimes it's easier to do the wrong thing and it's pretty much without harm. It doesn't mean we should stop trying to do the right thing.

sum dude said:
I like how you all are acting like people who write for abx for strep are going against standard of care. If you don't write for abx, you guys are naked in the breeze. It's not enabling by following textbook care for strep. Enabling is writing abx for a virus. I've never had an analphylaxis from amox I've written in ED on a kid, but seen plenty of PTA's and even a few strep sepsis kids. Give him 1st dose in ER, or give Bicillin if you are worried about reaction.
If you are worried about analphylaxis, you are going have a tough time writing any meds outside of albuterol. Seriously, how many meds on patients you need are actually necessary? They all cary risk of analphylaxis.
Feel free to stay on your EBM high horse, but the EBM nazi's are the same ones who led the charge to put central lines in stable patients with lactics of 4 (since overturned) and blood cultures on everyone. I'm all for physician and patient autonomy--if you convince someone abx aren't worth it, more power to ya.
Click to expand...

Which textbook are you referring to? Rosen's says antibiotics shouldn't be routinely used in strep throat (and following that textbook gives you added protection against Dr. Rosen should he target you to pad his bank account as a prosecuting expert witness). Looking over other professional organization websites, I'm not seeing any of them that say you should absolutely treat strep throat. They're all hedging, at the very least, and it looks like the pediatricians and family practice societies acknowledge that there's probably not much benefit to treating with antibiotics, even if their official policy still advocates testing and treatment.

I don't get railing against EBM. Sure, some errors are made, and I'm cool with people acknowledging that while what they're doing isn't in line with the latest EBM, they're going to do it anyway, because they're not comfortable changing their practice until more data becomes available. But using it like it's a bad word is the mindset that has the population pushing for laws to teach creationism instead of evolution in schools and failing to immunize their children.
 
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