Chicken soup for the sore throat often beats antibiotics

With several cost-effective tests available for diagnosing strep throat, overprescribing antibiotics for viral infections would seem to be a thing of the past. It's not.

By Susan J. Landers, AMNews staff. Aug. 4, 2003.

Washington -- Patients with raw, scratchy throats can be formidable opponents for harried physicians who lack the time for lengthy explanation as to why an antibiotic might not be in their best interest, or in the best interest of society at large. Instead, physicians often end up prescribing antibiotics for adult patients with sore throats without testing to see if streptococcal bacteria are the cause.

Many believe such widespread antibiotic prescribing is helping to fuel the spread of antibiotic resistance, which is already posing a significant threat to the nation's health.

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Sore throats are the sixth leading cause of adult visits to primary care physicians. Despite the fact that 90% of those sore throats are caused by viruses, the vast majority of these adults are sent home with a prescription for an antibiotic -- often a very powerful one.

"It's an interesting area because it is probably where we primary care doctors throw the most antibiotics for the least good cause," said Deborah Allen, MD, a family physician in Indianapolis and director of the Bowen Research Center at Indiana University School of Medicine.

90% of adult sore throats are caused by viruses.

"I have a lot of concerns about the overuse of antibiotics by physicians, especially in the cases of sore throats," said Mark D. Aronson, MD, a primary care physician at Beth Israel Deaconess Medical Center in Boston. "The routine use of these drugs by physicians, particularly the use of the broad- spectrum antibiotics, can lead to drug resistance, which can be hazardous to patients if they get a very serious infection." Most physicians concur that patient request is likely to be the main reason for antibiotic overprescribing.

"If a physician is under a lot of pressure to see as many patients as possible, it is easier to just sit down and write a prescription than it is to explain to them why they aren't getting a prescription," said Michael Gerber, MD, professor of pediatrics at the University of Cincinnati College of Medicine.

The situation is different for children, whose sore throats are much more likely to be caused by group A streptococcus. The consequences of an untreated strep throat are more serious in children because of the greater risk of rheumatic fever, noted Dr. Gerber.

Multiple testing available

A study in the July 15 Annals of Internal Medicine indicated that prescribing antibiotics without testing for strep is the least cost-effective strategy primary care physicians use when treating adult sore throats.

Researchers at Beth Deaconess Medical Center and Harvard University analyzed five strategies and concluded that all are more cost-effective than empiric treatment, said Dr. Aronson, who was an author of the study.

The researchers found that traditional throat culture was the most cost-effective diagnostic method, supplanting the rapid antigen test recommended by the American College of Physicians.

However, the conflict over which strep throat test to use plays a distant second when the first issue is that tests are rarely done at all.

Regardless of which test physicians use, it is important that one be conducted before prescribing antibiotics, said Dr. Aronson. Going forward with antibiotics without testing is the worst strategy, he said. The only time this approach can be cost-effective is when the chance of a strep throat is 75% or higher, for example when the infection breaks out within a family.

Before the 1950s when throat cultures became available, it was difficult for even the most experienced physician to tell the difference between viral pharyngitis and strep-caused pharyngitis. A diagnosis based on signs and symptoms still is difficult, said Dr. Gerber.

There are a few complexities that come with testing. For example, results from a throat culture aren't available for 24 to 48 hours and the newer tests, although they produce immediate results, sometimes produce false-negatives that must be verified with throat cultures.

Such wrinkles can be especially problematic in clinics and emergency departments, where physicians don't know the patients and might fear they won't return or call for test results. In those cases, physicians might be tempted to provide an antibiotic just in case, said Dr. Gerber.

Throat cultures became available in the 1950s.

Sending needy patients away is not an easy step -- even if it is a temporary one pending test results. "The big problem is you have to end up basically not giving the patient what they want, and that is a very difficult position," said Dr. Allen.

Also, a recommendation of chicken soup and lozenges is not likely to be what the patient wants, said Dr. Aronson. Although both may be appropriate, the patient will wonder, "Why am I going to the doctor?"

There is one group of patients that comes into the office and says, "I want an antibiotic if I need one. What do you think?" said Dr. Allen. She usually tells them that their symptoms do not point to a strep throat but takes the culture to confirm her diagnosis and assures them if it comes back positive, they will be treated. "Most of the patients will say, 'Fine.' "

But there also are patients who won't give up on the idea of an immediate antibiotic despite Dr. Allen's best efforts to convince them to wait until the conclusive answer is in. "If after 10 minutes they are still asking for an antibiotic, I say, 'Let's compromise and we'll start you on antibiotics, but you have to stop if it isn't strep.' "

Dr. Allen doesn't really believe that is the best solution. "But this isn't a one-sided relationship with most people. They come in with their expectations and you're trying to do what's in their best interest. I like the partnership model where they take part in their care."

ADDITIONAL INFORMATION:

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Information on antibiotic resistance from the CDC's National Center for Infectious Diseases (www.cdc.gov/drugresistance/factsheets)

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