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For those who are interested, We reviewed this cost-effectiveness
article as a PEM fellow.  This is based on rates of strep in children
age 5-17 years old. (didn't assess the extremes of age)  They tested
the cost effectiveness of 5 options

(1) “treat all,” (2) “treat none,” (3) “rapid test,” where only
patients with a positive rapid antigen test are treated, (4)
“culture,” where only patients with a positive throat culture are
treated, and (5) “rapid test with culture

 It takes into account, cost of missed GAS, cost of allergic
reactions. etc. (doesn't factor in litigation.) It found that for the
5-17 year age range, rapid strep only was the most cost effective
strategy.

Here is the link...
http://www.sepeap.org/archivos/pdf/10624.pdf

You could use the data provided to calculate an effective strategy for
other age ranges.

 I think management at the extremes (for all issues) is where the art
of medicine is revealed.  These decisions will be based on the risk
tolerance of the clinician and the patient/family, severity and
duration of illness, phase of the moon, number of patients in the
waiting room, etc.

Such is ART.

-Danny

Danny G Thomas MD MPH
Assistant Professor of Pediatrics
Medical College of Wisconsin



On Tue, Jun 1, 2010 at 3:24 PM, Dave Smith <[log in to unmask]> wrote:
> Of course it is anecdotal but it raises many interesting questions.  The most relevant of which is whether we can hang our hats on the idea that rheumatic fever "never" happens outside of certain age ranges.  While I was unusual in a whole host of ways, I don't know that you can say that it shows that treatment doesn't matter in all cases...just that sometimes, people get treated and still get RF.  Since we have to base our decisions on overall risks and probabilities and not just one case as you noted, and since the decline of RF in the States seems to be attributable to the onset of antibiotics and the routine treatment of strep, it still begs the question of whether or not we are kidding ourselves by not treating in non-traditional age groups just because "they don't get RF."
>
>
>
>
> ________________________________
> From: Fergus Thornton <[log in to unmask]>
> To: [log in to unmask]
> Sent: Mon, May 31, 2010 8:59:50 PM
> Subject: Re: Rapid Strep Test < 2 years old
>
> Anecdotal.  While I'm sympathetic to what happened to you, even you know that we can't base clinical decisions on one case.  We have to base our decisions on statistical probability not on one case.  In fact your case proves what we're saying: antibiotics shouldn't be used in this (or any? age group.  Didn't make a difference in your case.
>
> -----Original Message-----
>>From: Dave Smith <[log in to unmask]>
>>Sent: May 30, 2010 10:20 PM
>>To: [log in to unmask]
>>Subject: Re: Rapid Strep Test < 2 years old
>>
>>I am 41 and just recovered from Acute Rheumatic Fever that developed after an adequately treated GAS pharyngitis.
>>
>>(Without going into detail, diagnosis was arrived at by meeting Jones Criteria and having no other positives in my rheumatologic workup...rheumatology and infectious disease (Duke) evaluated me and concur)
>>
>>I am a white male, European descent, and never lived off the North American continent...shouldn't have happened.
>>
>>Try to incorporate that into this discussion....even I am not sure how it fits in or what one could learn from it.
>>
>>
>>R. David Smith, MD
>>Children's Acute Care
>>Medical Director, Peds Emergency
>>Christus Schumpert, Sutton Children's Hospital, Shreveport, LA
>>Cape Fear Valley Medical Center, Fayetteville, NC
>>
>>
>>
>>________________________________
>>From: "Mittal, Manoj K" <[log in to unmask]>
>>To: [log in to unmask]
>>Sent: Sun, May 30, 2010 10:18:20 AM
>>Subject: Re: Rapid Strep Test < 2 years old
>>
>>How about adults with sore throat? Do the EM physicians in the group test them for Strept. and treat with antibiotics if positive? Rheumatic fever complicates Strept throat only in children between 5-15 yrs (can stretch the age by 1-2 yrs at the margin to cover the outliers). So that is not an issue in adults as well (similar to children under the age of 3-4 yrs).
>>Manoj
>>Manoj K. Mittal, MD, MRCP (UK)
>>Division of Emergency Medicine
>>The Children's Hospital of Philadelphia
>>University of Pennsylvania School of Medicine
>>Philadelphia, PA
>>________________________________________
>>From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] On Behalf Of [log in to unmask] [[log in to unmask]]
>>Sent: Sunday, May 30, 2010 1:34 AM
>>To: [log in to unmask]
>>Subject: Re: Rapid Strep Test < 2 years old
>>
>>Antibiotics have not been shown to impact post-strep GN.  The only reason to treat is to reduce the rate of rheumatic heart disease, which in this age range, for all intensive purposes, does not occur.  Mike Falk
>>
>>Sent from my iPhone
>>
>>On 2010-05-29, at 7:09 PM, Fergus Thornton <[log in to unmask]> wrote:
>>
>>You talk about treating the disease; are you equating a + strep with the disease?
>>#2 is less than 24 hours; not worth a course of Ab's
>>#3 the latest I've read is that there is no relationship.
>>#4 What's the incidence of PSGN in this age group?
>>#5 doesn't occur in this age group
>>Nope, haven't convinced me yet to test or treat these kids with Ab's.
>>
>>-----Original Message-----
>>From: Kevin Powell <[log in to unmask]>
>>Sent: May 29, 2010 1:26 PM
>>To: [log in to unmask]
>>Subject: Re: Rapid Strep Test < 2 years old
>>
>>I treat strep infections
>>1.. to reduce contagion
>>2.. to speed healing and reduce suffering
>>3.. to reduce suppurative sequelae
>>4.. to reduce other sequelae, such as glomerulonephritis
>>5.. to prevent rheumatic fever
>>roughly in that order.
>>
>>I think the 1990 era teaching that treatment didn't reduce length of illness
>>was supplanted by 2000 with data showing 1 day fewer of symptoms by treating
>>typical strep pharyngitis in older children. No data in the toddlers. There
>>are lots of places in ER medicine where I would like to reduce exposing kids
>>to antibiotics. Disease with a proven bacterial pathogen is way down the
>>list.
>>
>>{SIDEBAR: Eliminating antibiotics for wheezing toddlers with minimal CXR
>>findings would be high on my list. This past year I've been working as a
>>hospitalist for pulmonology and I am frustrated with the number of consults
>>weekly that involve telling parents their child with recurrent pneumonias
>>doesn't have an immunodeficiency, he has undertreated asthma.}
>>
>>The risk/benefit of testing will be different in toddlers.  As I said
>>before, I don't routinely test for strep in toddlers with sore throats - far
>>too many viral illnesses. But if a sib has strep or other factors raise the
>>concern, it is appropriate to test toddlers and, unless shown an applicable
>>Bayesian analysis, I would recommend treating the disease when it is found.
>>
>>If an institution has a protocol in place to do rapid streps in triage on
>>all children with fevers or sore throats, I have minimal experience
>>practicing that way and defer to others to cite references on that protocol
>>applied to toddlers.
>>
>>Kevin Powell MD PhD FAAP
>>SSM Cardinal Glennon Children's Medical Center
>>Associate Professor of Pediatrics
>>Saint Louis University
>>
>>-----Original Message-----
>>From: Chamberlain, Jim [mailto:[log in to unmask]]
>>Sent: Saturday, May 29, 2010 8:52 AM
>>To: Kevin Powell; [log in to unmask]
>>Subject: Re: Rapid Strep Test < 2 years old
>>
>>
>>But the reason we treat Strep is to prevent rheumatic fever. Children this
>>age don't get RF. Data on symptom resolution suggests a minimally faster
>>improvement if treated. So why expose all these kids to antibiotics?
>>
>>
>>For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>>The URL for the PED-EM-L Web Page is:
>>              http://listserv.brown.edu/ped-em-l.html
>>
>>
>>Fergus Thornton
>>read my blog @ http://docdownunder.wordpress.com
>>
>>For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>>The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>>
>>
>>
>>
>>For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>>The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>>For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>>The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>>
>>
>>
>>
>>
>>For more information, send mail to [log in to unmask] with the message: info PED-EM-L
>>The URL for the PED-EM-L Web Page is:
>>                http://listserv.brown.edu/ped-em-l.html
>
>
> Fergus Thornton
> read my blog @ http://docdownunder.wordpress.com
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
>
>
>
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html