Drugs & MedicationsEye, Ear, Nose. ThroatInfectious DiseasesPreventive Medicine


When it comes to medical protocols, the symbolic pendulum swings back and forth all the time. Many concepts in medicine are subject to variations in validity and truth. Medical research is an ongoing phenomenon that seeks to confirm or refute proven data or concepts. In other words, medical scientists are continually trying to knock a concept, or rule, off its lofty perch by proving data to the contrary. One thing in medicine is certain: there is always uncertainty about the acceptance of a concept. Once a concept gains majority approval, other researchers are either trying to replicate the results, or disprove its conclusion by the same means. From one year to the next, protocols may change 180°. Nothing remains certain. 

For instance, many attempts have been made to disprove the efficacy of statin drugs in reducing the rates of sudden cardiac death, but no one has been able to present a negative result from statins. Sudden cardiac deaths are reduced by statins and each study reaches that same conclusion. The statin pendulum has remained solidly on the side of benefit. 

When it comes to the diagnosis and treatment of sore throats, however, the pendulum now rests on the nihilistic side where antibiotics are used only for the reduction of symptoms. For decades, Acute Rheumatic Fever and Acute Glomerulonephritis were worrisome post-streptococcal infections. Because of that major concern, a 10-day course of antibiotics was prescribed for every throat that tested Positive for Group A Beta-Hemolytic Streptococcus (GABHS). The pendulum had swung toward favoring antibiotics. But today, in the U.S., the incidence of rheumatic fever is 1 in 100,000 children per year so antibiotics are not mandatory.

“In 2023, an international group of experts in primary care respiratory infections published the first international guideline for the management of sore throat. The guideline focuses on avoiding testing and antibiotic use for patients with uncomplicated sore throat (i.e. mild to moderate sore throat, accompanied by cough, with no red flags), reserving evaluation, testing, and possibly antibiotic use for those at risk of complicated or severe disease.” Several European countries recommend against rapid antigen testing for strep and the use of antibiotics for any children with uncomplicated sore throat.  

The reason for this shift in attitude comes from the fact that the majority of sore throats are viral. But when GABHS had the reputation of causing rheumatic fever, antibiotics were prescribed indiscriminately as a deterrent to causing those dreaded complications. In 40 years, I never knowingly saw a case of acute rheumatic fever. Was that because I, and many other physicians, over-prescribed antibiotics, or was it because the natural evolution of post-streptococcal infections reduced the number of cases that occurred. I don’t really know. 

I do know that antibiotics are helpful in the 10% of adults and 20%-30% of children with sore throats whose rapid strep test is positive. Today’s rapid antigen strep tests are more sensitive than older tests so more patients are testing positive for GABHS and thus doctors need to be certain that patients prescribed antibiotics really need them. “Backup” throat cultures are recommended to confirm GABHS and the need for antibiotics. This protocol is certain to determine who should and shouldn’t receive antibiotics. The pendulum has swung away from antibiotics. 

Prescribing antibiotics has been drilled into the minds of patients who are programmed to think every sore throat needs an antibiotic. That makes the patient mentally feel better, but actually may not be necessary because there’s a 70%-90% chance the sore throat is viral. 

My approach to this dilemma would be to test every one with a sore throat while knowing if they also have a cough or runny nose there’s an almost 0% chance of strep. Then, I would only prescribe antibiotics for patients who test strongly positive for GABHS, have a sore throat as their only symptom, and whose throat has the classic appearance of strep. Then, I wouldn’t be ignoring folks who are sick nor would I be over-prescribing antibiotics. 

If this protocol fails, and we see a surge in post-streptococcal infections, a re-evaluation will need to be done. The pendulum will keep shifting. 

References: Ebell MH, Barry HC. Management of Sore Throat: Time to Update. Am Fam Phys 2024 April;109(4):301-302.

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