OK, I've stayed out of this, in part because I agreed with Kevin Powell's
comments and didn't want to be redundant, but seriously?  When I start to
feel streppy because some kid I did a strep test on coughs in my face, I
am thrilled when the swab they do at employee health comes back positive.
Thanks to the wonders of post-1943 medicine, I know I'll be feeling better
in 12 hours and don't need to try to swap my shift the next day, know I
will be productive again, know I can manage my own contagion.  And of
course I take antibiotics!

I do lots of pain drops for viral otitis, and am scrupulously parsimonious
even when parents of adenoviral children wail and get in my face.  I swab
children less than three years once or twice a year, I quote the red book,
and even when they have exudates and a positive family contact if the
rapid is negative, too bad: no antibiotics for you.  But in the face of a
positive bacterial contagion, the "high likelihood" of an adverse reaction
doesn't stop me from gratefully getting treatment myself; bacterial
illness is what antibiotics are for.  I fight the good fight against
antibiotics for viral illnesses on a daily basis, but good heavens, if I
have strep, DELUGE me, and that goes double for the patients who entrust
their time, health, comfort, and money in me.

Double penicillin latte for me, please.


Fergus Thornton <[log in to unmask]> writes:
>"Primum non nocere"
>Giving a course of Ab with a high likelihood of an adverse reaction for
><24hr sooner relief
>violates this.  Many of you seem to be looking at this from the
>perspective of one child (yours!) but multiply this by 10,000/day to get
>a sense of the unnecessary antibiotics given in the US daily. This is
>difficult to justify.  I'm sorry your kid has one extra day of a sore
>throat but really . . . . is it worth deluging the world with more
>-----Original Message-----
>>From: "Chamberlain, Jim" <[log in to unmask]>
>>Sent: Jun 1, 2010 10:51 PM
>>To: [log in to unmask]
>>Subject: Re: Strep--Other Considerations
>>I agree with you about shortening the course of disease.
>>I disagree that we should lower ourselves so we are practicing at the
>lowest common denominator. We need to educate our parents (and
>administrators) about the risks and benefits of medications. Otherwise,
>we should just put a large vat of amoxicillin in our waiting rooms and
>let parents decide when they want antibiotics.
>>James Chamberlain, MD
>>Division Chief, Emergency Medicine
>>Children's National Medical Center
>>111 Michigan Avenue, NW
>>Washington, DC 20010
>>202.476.3253 (O)
>>202.476.3573 (F)
>>202.476.5433 (Emergency Access)
>>-----Original Message-----
>>From: Pediatric Emergency Medicine Discussion List
>[mailto:[log in to unmask]] On Behalf Of Dave Smith
>>Sent: Tuesday, June 01, 2010 4:29 PM
>>To: [log in to unmask]
>>Subject: Strep--Other Considerations
>>I want to play devil's advocate for a moment on another set of
>>1.  What is the impact of not treating in terms of outcomes not
>considered by studies?
>>What I mean by this is that it is all well and good to pound the table
>and hold up the studies and say, "Best practice says I don't need to
>test/treat your 2 year old son, Mrs. Smith," but then, how often does
>Mrs. Smith go to the urgent care down the road where they invariably see
>a febrile toddler, order blood, urine and a chest xray, and give
>Rocephin?  Even if she goes to her PMD the next day and they simply do a
>strep and treat (which I think most PMD's would do despite our urgings to
>the contrary), she's now incurred another visit to another medical
>provider, increasing overall costs in the process.  In the former
>case, the child undergoes a while slew of tests and a treatment we could
>have prevented.  As I like to say, Evidence-Based Medicine is the
>beginning of wisdom, not the entirity of it.  We also have to practice
>"realistic medicine" ."  Over-adherence to dogma may lead to
>parents seeking other outlets that end up doing far worse
>> than a script for PenVK.  Writing that script in some (many?) cases
>would thus be better practice than what the child ended up with even
>though it may not have been "best practice."
>>2.  We live in a world of Press-Gainey
>>If your hospital administrators are like ours, they don't really care
>about the best-practice guidelines...just the satisfaction scores.  When
>surveys come back giving the doctor a series of 1's because they doctor
>"didn't do anything about my child's strep throat and I had to go to an
>urgent care" they want to know what we are doing to improve our scores. 
>Telling them that strep only gets better a day earlier with treatment and
>the child wasn't in an age range for rheumatic fever so it didn't matter
>isn't something they care about.  That's how one ends up with language
>added to one's contract tying incentives and penalties to Press-Gainey
>>3.  What's a day worth to a parent/child?
>>When your child is sick, would you like him to be better a day
>earlier?  As a parent of four, I would have to say my answer is yes. 
>Most parents I see would say yes as well.  That extra day could be two
>extra days in some cases and we have no way of knowing for
>could also be zero, but few parents would see that as an issue if there
>is a good chance the illness could be one or two days shorter.  For
>parents who are working, sometimes in positions where taking more sick
>days could mean not advancing or at the very least, being seen as
>unreliable because they are always out with "kid issues," that extra day
>might mean a lot.  So when we say, "It's not worthwhile because they
>only get better a day earlier at best," we are making a value judgement
>about the worth of a day of wellness and the value of the parents' time.
>>As I said, just playing devil's advocate.  I tend to agree in principle
>with what others have written in this thread.  But we must always
>remember that there are times when we still may be doing better care,
>given the balance of all the issues at hand, when we give a little ground
>on "best care."
>>Dave Smith, MD
>>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:
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>Fergus Thornton
>read my blog @
>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:

Amy Baxter MD
Pediatric Emergency Medicine Associates
404 371-1190

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