Strep Pharyngitis

[Solideliquid]

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So my dad went to an urgent care center because he has been feeling terrible the last day or two, also with a sore throat.

So the doc does a rapid strep test and it's positive. I went over to my parents house last night for dinner and I ask him what medications the doctor prescribed. Well he had not gone to the pharmacy yet so he handed the script over. Omnicef PO BID x10 days. I thought it was a little much to prescribe a 3rd generation ceph for strep pharyngitis.

All my literature says all you need is penicillin or a macroclide for 10 days and it should knock it right out. Have there been any studies or new research suggesting the usage of these powerfull (and expensive) antibiotics?

Am I just overreacting or does this seem like another case of irresponsible antibiotic usage?

 

[sdn1977]

Well....there are lots of antibiotics that will treat a strep pharyngitis. So much depends upon the local resistance patterns within each community. Its difficult to presume what that might be. Also, his own concurrent illness may contribute to the choice....but then you know that.

In circumstances like this, when an expensive antibioitic has been prescribed & if it becomes difficult to the pts financial situation or the pt is reluctant to obtain it, I contact the prescriber - usually it is not the initial physician due to elapsed time. However, I've always found the following prescriber was willing to prescribe an alternative which is financially more suitable to the circumstance.

I don't really think you're asking for advice....but, I don't think its irresponsible - it is the community standard which the prescriber feels comfortable with. However, it is easily remedied, IMO.

 

[Solideliquid]

No he can afford it, and I didn't tell him he should call his doctor or anything. I'm just happy with him taking his medicine! If I expressed my concerns he would probably use it as an excuse to delay treatment he hates taking medicine.

LOL.

Thanks for the help, I was mostly wondering if there is new data around. She couldn't have known this particular bug's sensitivity because she didn't do a culture or take blood.

 

[Idiopathic]

Plenty of people say that strep will never be more than slightly resistant to a first generation beta lactam. Likely the choice of omnicef was based on recent pharm rep visit, and that drug is so $$$$ that it doesnt make much sense. BUT, you also never know about what kind of patterns this doc is seeing. He may have been getting some resistant bugs in his office. But likely a drug rep got in his ear.

 

[aus1ander]

So my dad went to an urgent care center because he has been feeling terrible the last day or two, also with a sore throat.

So the doc does a rapid strep test and it's positive. I went over to my parents house last night for dinner and I ask him what medications the doctor prescribed. Well he had not gone to the pharmacy yet so he handed the script over. Omnicef PO BID x10 days. I thought it was a little much to prescribe a 3rd generation ceph for strep pharyngitis.

All my literature says all you need is penicillin or a macroclide for 10 days and it should knock it right out. Have there been any studies or new research suggesting the usage of these powerfull (and expensive) antibiotics?

Am I just overreacting or does this seem like another case of irresponsible antibiotic usage?

It is my understanding that the cephalosporins can be used in patients with milder PCN allergies because they are superior to macrolides at bacterial eradication. I was too lazy to do a pubmed search, but UpToDate has an interesting dicussion on the use of cephalosporins (including Omnicef) in the treatment article for GAS. According to their analysis, there have been meta-analyses done that have shown the ceph's are superior to PCN at bacterial eradication of GAS.

 

[sdn1977]

I may have missed this, but I didn't see any PCN allergy in the original OP post. I think the OP was questioning why not a Z-pk or Biaxin or some such. Certainly the recent erythromycins would be an advantage if a defined allergy which was documented.

Well - we get monthly sensitivity reports from the pathology dept on resistance patterns in the pharmacy, so we see prescribing patterns change as resistance patterns change (which helps us anticpate need). I'm sure the ER/Urgent care gets it as well. So..yes..sensitivity becomes an issue, especially if it is the primary situation or if there have been other extenuating circumstances (ie prophylaxis with a ceph. for a dental procedure 2 months before, exposure to grandchildren with chronic ear infections, etc..)

There always could be a drug rep visit, but Urgent care folks rarely have time for that & the insurance copays will ALWAYS override that influence.

 

[Solideliquid]

Quick update fellas!

I just called him to ask how he's doing. He said he is feeling much better! He paid $120 for the prescription!!! SHIZAM!


He also said he remembered a few years ago he had strep and he got penicillin.

Go figure.

EDIT: His allergies status is NKDA.

 

[Solideliquid]

It is my understanding that the cephalosporins can be used in patients with milder PCN allergies because they are superior to macrolides at bacterial eradication. I was too lazy to do a pubmed search, but UpToDate has an interesting dicussion on the use of cephalosporins (including Omnicef) in the treatment article for GAS. According to their analysis, there have been meta-analyses done that have shown the ceph's are superior to PCN at bacterial eradication of GAS.

This has to be a new trend, especially as GAS pharyngitis IS self limiting in the immunocompetent AND usually is alleviated by the immune system in 4-12 days.

 

[southerndoc]

I usually treat with an IM injection of bicillin. Cheap and effective usually. I rarely write prescriptions for oral medications unless the person specifically requests it instead of the injection. Most prefer the injection though.

 

[Solideliquid]

I usually treat with an IM injection of bicillin. Cheap and effective usually. I rarely write prescriptions for oral medications unless the person specifically requests it instead of the injection. Most prefer the injection though.

Your sig kicks butt!

 

[TBforme]

Fresh off my FP and Peds rotations, I will say: Penicillin is 1st line tx according to every society/committe on the matter. (Technically, amoxicillin is an alternative, although it's so tasty it is 1st line in peds). The studies on the prevention of ARF were done with PCN in the 50s. GAS is universally sensitive to PCN. Tx failures with PCN have not been associated with the development of ARF. Cephalosporins may be better at the eradication of the carrier state, but no difference for the complications that matter. GAS is not treated for the pharyngitis but for the complications--local and ARF.

As an aside, your dad probably did not even have GAS pharyngitis. It is really quite uncommon in adults with some studies claiming a prevalence of <5% . GAS carrier status with concurrent viral pharyngitis is more likely, especially since he alledgedly had strep a few years ago.

 

[docB]

I usually treat with an IM injection of bicillin. Cheap and effective usually. I rarely write prescriptions for oral medications unless the person specifically requests it instead of the injection. Most prefer the injection though.

I usually only subject the homeless to the bicillin butt lump after I ask them if they would rather have a really painful one time injection or a script they can't fill. PCN for everyone else. Azithro for the PCN allergic. And this reminds me of something for the "What are the biggest problems in the ED" thread: bogus allergies.

 

[sdn1977]

I usually treat with an IM injection of bicillin. Cheap and effective usually. I rarely write prescriptions for oral medications unless the person specifically requests it instead of the injection. Most prefer the injection though.

OUCH! ouch...ouch...ouch.......ever had that yourself???? Yep...cheap, effective & very, very painful!!! Do they prefer it because you offer it or because they've had it before? I've had it - would never do it again. But..to each his own - it would work for sure...just wouldn't be my choice.

 

[sdn1977]

I usually only subject the homeless to the bicillin butt lump after I ask them if they would rather have a really painful one time injection or a script they can't fill. PCN for everyone else. Azithro for the PCN allergic. And this reminds me of something for the "What are the biggest problems in the ED" thread: bogus allergies.

Yep, yep...bogus allergies - it causes 9/10 calls I make to the ED physician. Have you ever thought about writing on the rx: "no pcn allergy - eryth - Gi distress only". Thats all it would take for me to not call you. Unfortunately, I have to document too, but if you can help me, I'd bother you less on the phone 😳 .

 

[OSUdoc08]

So my dad went to an urgent care center because he has been feeling terrible the last day or two, also with a sore throat.

So the doc does a rapid strep test and it's positive. I went over to my parents house last night for dinner and I ask him what medications the doctor prescribed. Well he had not gone to the pharmacy yet so he handed the script over. Omnicef PO BID x10 days. I thought it was a little much to prescribe a 3rd generation ceph for strep pharyngitis.

All my literature says all you need is penicillin or a macroclide for 10 days and it should knock it right out. Have there been any studies or new research suggesting the usage of these powerfull (and expensive) antibiotics?

Am I just overreacting or does this seem like another case of irresponsible antibiotic usage?

100% of cases I have seen have recieved Amoxicillin (or Azithromycin if PCN allergy.)

I've always recieved Amoxicillin, and it costs $5 after insurance. It works every time.

 

[Idiopathic]

100% of cases I have seen have recieved Amoxicillin (or Azithromycin if PCN allergy.)

I've always recieved Amoxicillin, and it costs $5 after insurance. It works every time.

Pen-Vee K still drug of choice.

 

[tRmedic21]

Doing FP now, and it's always been 100% amoxicillin or azithromycin in our office.

I think a $120 script for strep pharyngitis is probably irresponsible. As mentioned above, perhaps it's related to local resistance patterns, but that seems unlikely to me. I can't imagine a family doc who would go that route when there are plenty of other antibiotics that could and would do the trick, for a fraction of the cost. Sounds like the influence of a drug rep to me, too, sadly.

Even if the patient has insurance, shouldn't we as doctors (ok, future doctor for me) be concerned about things like this? Cost is a major factor for our patients and I think it is our responsibility to take these kinds of things into account, and how it affects our heal care system as a whole. Yes... if an expensive medication is needed, then fine... but what would happen if every doc in the country started treating GAS with a $100+ antibiotic? Besides all the drug reps getting new Jags, that is... 🙄 I think we should be doing what we can to help control the cost of healthcare, not the opposite.

 

[jashanley]

I usually do the same as southerndoc. IM Benzathine PCN x 1 dose. I tell them it hurts but there will be no pills to take and 1 shot you are done. Most if not all take the shot given the choice. I can't recall writing for pills in a patient in the last 4 yrs, unless they have a PCN allergy.
Has anyone seen data on using the azithromycin single dose for strep pharyngitis or anyone use it? Seems convenient albeit expensive.
I like convenient and single dose regimens to improve compliance. I am biased from working in the ED.

 

[sdn1977]

I usually do the same as southerndoc. IM Benzathine PCN x 1 dose. I tell them it hurts but there will be no pills to take and 1 shot you are done. Most if not all take the shot given the choice. I can't recall writing for pills in a patient in the last 4 yrs, unless they have a PCN allergy.
Has anyone seen data on using the azithromycin single dose for strep pharyngitis or anyone use it? Seems convenient albeit expensive.
I like convenient and single dose regimens to improve compliance. I am biased from working in the ED.

There was work printed in the Pediatric Infectious Disease Journal, 2005 comparing azithromycin 30mg/kg single dose against a 3-5 day course & traditional amoxicillin dosing for otitis media. The single dose was as effective.

Also, in Infection, 1999, I think, they compared single 1.5G dose against benzathine pcn for syphilis & it was equally effective.

I think there is also another reference in NEJM Sept '05 comparing single dose azithromycin in community acquired pneumonia. I can't recall the regimens it was being compared to.

If you are interested, I'll get more complete citations - just don't have them at the tip of my fingers right now.

Azithromycin is a great drug - pts love it, few side effects, they are very compliant, liquid requires no refrig so travelers love it, now its generic its chearp......and....best of all - it doesn't hurt!

 

[CANES2006]

OUCH! ouch...ouch...ouch.......ever had that yourself???? Yep...cheap, effective & very, very painful!!! Do they prefer it because you offer it or because they've had it before? I've had it - would never do it again. But..to each his own - it would work for sure...just wouldn't be my choice.

Are you kidding? I've taken it twice for Strep throat and I would do it again in a heart beat. It is super efficient and you don't run the risk of missing a dose. It's not painful at all. You are such a baby! 😉

 

[southerndoc]

OUCH! ouch...ouch...ouch.......ever had that yourself???? Yep...cheap, effective & very, very painful!!! Do they prefer it because you offer it or because they've had it before? I've had it - would never do it again. But..to each his own - it would work for sure...just wouldn't be my choice.

Yes I've had a shot of bicillin before, and no, it didn't hurt. Are you sure you aren't confusing bicillin with unbuffered ceftriaxone? Ceftriaxone hurts, bicillin doesn't.

 

[12R34Y]

Yes I've had a shot of bicillin before, and no, it didn't hurt. Are you sure you aren't confusing bicillin with unbuffered ceftriaxone? Ceftriaxone hurts, bicillin doesn't.

I'll have to agree that bicillin does hurt, but not bad at all. Definately worth getting the shot over pills/filling scripts/missed doses etc...

the ED I work in gives bicillin first, if patient is a baby and doesn't want shot then amoxicillin, if allergic to pcn, then azithro.

later

 

[Poety]

Tetanus and the Hep series hurts 😳

 

[southerndoc]

Tetanus and the Hep series hurts 😳

So do papercuts.

 

[teleo1]

So do papercuts.

lol

 

[sdn1977]

I admit I'm a bit of a baby about injections. But....this was a particularly bad one & since I was an inquisitive pharmacy student at the UCSF student health center, I asked to see what I was given. It was Bicillin LA (& a mistake)! Did you know there are two Bicillins???? - LA & CR. Both can be used for mild-moderate URI's with strep, but the LA is MUCH, MUCH, MUCH more painful than the CR.

The LA is normally used for rheumatic fever prophylaxis or syphillis primarily because it provides a sustained altho lower level of pcn than CR. CR is a 50:50 mixture of procaine pcn & benzathine pcn - the procaine pcn provides moderately high levels on day one & then the benzathine portion sustains for 3-5 days. Less benzathine - less pain. The LR pain can last up to 3 days - ask your syphillis pts!

So...when you write an order for benzathine penicillin (or Bicillin) 1.2 MU - do you know what the nurses get from the refrigerated pyxyis unit? Both have the name Bicillin, have the same strengths & have similar packaging. This a very common mixup in the ER/urgent care units - only because the nurses don't know one should never be used for syphillis.

You may think this mistake is not that common, but there was a huge error reported in JAMA 2005 which occurred at the LA County Dept of Health - for 5 years, pts were given the wrong Bicillin when they were being treated for syphillis. A total of 429 pts were affected. The error originated with the pharmacy, but went unnoticed by the physicians. A pt noticed the error. So...do you order benzathine pcn, Bicillin, Bicillin CR or Bicillin LA & do you ever check to see what was really given? You'll know if they say that shot really, really hurt! 😉