Dave Smith wrote:
"The rapid test done by optical immunoassay (OIA) is the ojne that was
studied on a large scale in an office-based setting and found to have
equivalent sensitivity and specificity to culture."
This is NOT true. The key is what Brent King said in his posting. In office
practices sheep blood agar is used for TC. This is not very sensitive.
Hospitals use more selective media with Bacitracin disks etc to
selectively inhibit non GABHS and overcome the competitive inhibition by
these bacteria on GABHS. Bottom line is that the OIA and the Latex
agglutination have about 80-90 % sensitivity, so one should follow up with
a reliable culture.
I am also not prepared to accept "no treatment" as an option. David Green
in his posting talked about recurrence and contagiousness, which,
especially in a school setting, may translate into more school days lost +
more work days lost for parents!!. Moreover, if one of these kids develops
ARF and you chose the "no treatment" option, what leg do you have to stand
on?? The consequences as you all know is valvulitis and a scarred mitral or
aortic valve or both, with all its attendant complications/morbidity for
The issue of symptomatic relief is not so obvious and intuitive as it has
been made out by some respondents. If you read James Todd from Denver
Childrens, who has written a fair bit on strep pharyngitis, the symptomatic
relief is most evident in kids who are clinically strongly suspected to
have strep. This includes tonsillar exudates, fever, palatal petechiae, the
famous "odour", scarlatiniform rash, Pastia lines, strawberry tongue,
reactive cervical lymphadenopathy etc etc.
For those kids with just a scratchy throat and fever, the symptomatic
relief is less evident or non at all! It is precisely these kids that I
don't waste time doing a rapid test on ( only a culture). Besides there is
some evidence that by waiting for the culture, the additional 48 hours
elapsed allows antibodies to develop in these mild cases???
In our hospital, all negative RS are followed up with culture. All positive
cultures are reported to us. We have the option of doing both tests or one,
as Dr Herman had stated.
BTW, what's the deal with steroids and promising rechecking in 2 days for
abscess in triage for strep pharyngitis whether they are well or not?? It
may not fly well with your group. Steroids have no proven benefit in strep
pharyngitis. Moreover, if you see someone, in triage or otherwise, make
sure you document it as an ED visit.
[ref: Mark Abel wrote-I personally treat homeless/care less folkswith LA
Bicillin IM, and promise to meet them in triage, without signing in, in 2
days (to check
for abscess). The rest I culture, give ibuprofen and hydrocodone syrup -
because it worked for me - and prednisone if they're real bad.]
Jay Pershad, MD
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