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my response to whether or not we discuss this again, is that obvioulsy there was no consensus the last time around.  prehaps a second try is in order given the wide disparity in practice that we as a community seem to have?
mike falk.

--- On Wed, 2/22/12, Kevin Powell <[log in to unmask]> wrote:


From: Kevin Powell <[log in to unmask]>
Subject: Re: question about strep
To: [log in to unmask]
Date: Wednesday, February 22, 2012, 3:52 AM


There was a heated discussion about this 21 months ago. The threads are
attached, though I can't really recommend wasting time on them since only 3
of the 44 posts cited any literature.
If really interested, see references in the posts for
5/27/2010 21:04
5/28/2010 18:05
6/01/2010 17:11

Kevin Powell MD PhD FAAP
Associate Professor of Pediatrics
Saint Louis University


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Hello everyone,

Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep
test and they're coming back positive. One of our PAs is claiming that he's
had 5-10 positives in the past 2 months. It seems pretty unusual for strep
pharyngitis to be present in a child < 2 years old (from what I recall).

Any thoughts? Is the disease profile changing? They're all carriers?

Thanks,
Fred

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It's been so long since I tested anyone under age 3 that I can't remember.
Rheumatic fever is rare enough and I don't know of any cases under age 3.



Taj Madiwale, MD

Univ of Tennessee

TC Thompson Children's Hospital

> Date: Thu, 27 May 2010 18:03:46 -0700
> From: [log in to unmask]
> Subject: Rapid Strep Test < 2 years old
> To: [log in to unmask]
>
> Hello everyone,
>
> Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep
test and they're coming back positive. One of our PAs is claiming that he's
had 5-10 positives in the past 2 months. It seems pretty unusual for strep
pharyngitis to be present in a child < 2 years old (from what I recall).
>
> Any thoughts? Is the disease profile changing? They're all carriers?
>
> Thanks,
> Fred
>
> 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

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From the Red Book (AAP Committee on Infectious Diseases), 2009:

"Toddlers (1 through 3 years of age) with GAS respiratory tract
infection initially can have serous rhinitis and then develop a
protracted illness with moderate fever, irritability, and anorexia
(streptococcal fever). The classic presentation of streptococcal upper
respiratory tract infection as acute pharyngitis is uncommon in children
younger than 3 years of age. Rheumatic fever also is rare in children
younger than 3 years of age."

The rest of the chapter is silent on treatment in this age group.

It has been my practice not to test or treat in children < 3 y.o. unless
there is difficulty in eradicating Strep from a family, but this is
usually the domain of the PCP, not me.



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 Fred Wu
Sent: Thursday, May 27, 2010 9:04 PM
To: [log in to unmask]
Subject: Rapid Strep Test < 2 years old

Hello everyone,

Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid
strep test and they're coming back positive. One of our PAs is claiming
that he's had 5-10 positives in the past 2 months. It seems pretty
unusual for strep pharyngitis to be present in a child < 2 years old
(from what I recall).

Any thoughts? Is the disease profile changing? They're all carriers?

Thanks,
Fred

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Any explanation on all the positive rapid strep tests in the below age
group? Is it all GAS respiratory tract infection?



Fred



-----Original Message-----
From: Chamberlain, Jim [mailto:[log in to unmask]]
Sent: Thursday, May 27, 2010 7:04 PM
To: Fred Wu; [log in to unmask]
Subject: RE: Rapid Strep Test < 2 years old



From the Red Book (AAP Committee on Infectious Diseases), 2009:



"Toddlers (1 through 3 years of age) with GAS respiratory tract

infection initially can have serous rhinitis and then develop a

protracted illness with moderate fever, irritability, and anorexia

(streptococcal fever). The classic presentation of streptococcal upper

respiratory tract infection as acute pharyngitis is uncommon in children

younger than 3 years of age. Rheumatic fever also is rare in children

younger than 3 years of age."



The rest of the chapter is silent on treatment in this age group.



It has been my practice not to test or treat in children < 3 y.o. unless

there is difficulty in eradicating Strep from a family, but this is

usually the domain of the PCP, not me.







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 Fred Wu

Sent: Thursday, May 27, 2010 9:04 PM

To: [log in to unmask]

Subject: Rapid Strep Test < 2 years old



Hello everyone,



Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid

strep test and they're coming back positive. One of our PAs is claiming

that he's had 5-10 positives in the past 2 months. It seems pretty

unusual for strep pharyngitis to be present in a child < 2 years old

(from what I recall).



Any thoughts? Is the disease profile changing? They're all carriers?



Thanks,

Fred



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Occasional positives, perhaps carriers.

On Thu, May 27, 2010 at 9:03 PM, Fred Wu <[log in to unmask]> wrote:

> Hello everyone,
>
> Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep
> test and they're coming back positive. One of our PAs is claiming that
he's
> had 5-10 positives in the past 2 months. It seems pretty unusual for strep
> pharyngitis to be present in a child < 2 years old (from what I recall).
>
> Any thoughts? Is the disease profile changing? They're all carriers?
>
> Thanks,
> Fred
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
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>



--
"I would rather be the kind of person who makes molehills out of mountains,
then mountains out of molehills."

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Toddlers (1-3 y/o) with GAS respiratory tract infection usually have a
serous rhinitis and then develop a protracted illness with moderate fever,
irritability and anorexia.  The classic presentation of streptococcal URI as
acute pharyngitis is uncommon in children younger than 3 y/o.  Rheumatic
fever also is rare in children younger than 3 years of age.  This is out of
the Red Book.  Testing is generally limited to daycares where there are
outbreaks and other at risk kids.
 
Robert J. Cooper, MD, FAAP
Orlando Medical Director
After Hours Pediatrics
[log in to unmask]




________________________________
From: Fred Wu <[log in to unmask]>
To: [log in to unmask]
Sent: Thu, May 27, 2010 9:03:46 PM
Subject: Rapid Strep Test < 2 years old

Hello everyone,

Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep
test and they're coming back positive. One of our PAs is claiming that he's
had 5-10 positives in the past 2 months. It seems pretty unusual for strep
pharyngitis to be present in a child < 2 years old (from what I recall).

Any thoughts? Is the disease profile changing? They're all carriers?

Thanks,
Fred

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Sarah Long, the esteemed Infectious Disease doc, told me many years ago that
strep is merely a disease of crowding.  Therefore, when children didn't
crowd together much before the advent of daycare, they didn't get sick w
strep much until starting school.  If children are enrolled in daycare,
there's no reason why they can't get strep throat.



James Reingold, M.D.

Cardon Children's Hospital

Mesa, AZ

> Date: Thu, 27 May 2010 18:03:46 -0700
> From: [log in to unmask]
> Subject: Rapid Strep Test < 2 years old
> To: [log in to unmask]
>
> Hello everyone,
>
> Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep
test and they're coming back positive. One of our PAs is claiming that he's
had 5-10 positives in the past 2 months. It seems pretty unusual for strep
pharyngitis to be present in a child < 2 years old (from what I recall).
>
> Any thoughts? Is the disease profile changing? They're all carriers?
>
> Thanks,
> Fred
>
> 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

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We did have a rash of positive streps last month. I once had 8 positives in
one 8 hour shift that got me wondering about it. We have also had a couple
of retropharyngeal abscesses due to Gp A strep.
this month, things seem to be quieting down.
How can one justify not treating a kid with positive strep, high fever and
even sometimes a classic rash?
Usha Sethuraman
Children's Hospital of Michigan

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But do they have the disease?  A pos strep and a high fever isn't something I'd treat.  Not unless it's a classic throat picture.  Usually these kiddies have a red throat with fever and I wouldn't treat that in spite of the +RST.  I also consider the fact the incidence of a neg rxn to a drug is higher than the amount of improvement such that they're really better off without Abs.


-----Original Message-----
>From: "Sethuraman, Usha" <[log in to unmask]>
>Sent: May 28, 2010 10:45 AM
>To: [log in to unmask]
>Subject: FW: reg strep positives
>
>We did have a rash of positive streps last month. I once had 8 positives in one 8 hour shift that got me wondering about it. We have also had a couple of retropharyngeal abscesses due to Gp A strep.
>this month, things seem to be quieting down.
>How can one justify not treating a kid with positive strep, high fever and even sometimes a classic rash?
>Usha Sethuraman
>Children's Hospital of Michigan
>
>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 @ http://docdownunder.wordpress.com

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I'm just speaking for myself but I think we've hit the main points in this
debate, perhaps we could move on.



James

> Date: Mon, 7 Jun 2010 14:17:15 -0400
> From: [log in to unmask]
> Subject: Re: Strep--Other Considerations
> To: [log in to unmask]
>
> UTI's lead to pyelo in a certain % of cases. There is no evidence that not
treating leads to PTA.
>
>
> -----Original Message-----
> >From: Amy Baxter <[log in to unmask]>
> >Sent: Jun 3, 2010 4:17 PM
> >To: [log in to unmask]
> >Subject: Re: Strep--Other Considerations
> >
> >I have strep about three times a year since I moved to Atlanta, about
once
> >per year before that. SEveral times I have been unable to get to be
> >tested, and I am feverish and miserable and going to sleep at 0830PM
until
> >I get to employee health or the doctor to get the swab. I don't take amox
> >unless I know for sure it's strep, but each time this has happened I feel
> >much better within 12 hours of starting antibiotics and the fever goes
> >away. I'm not saying other people get better that fast, although when
> >I've been camp doctor I see similar resolution of strep with abx but not
> >strep negative with no abx. My personal N is about 16. The longest I've
> >been uncomfortable and feverish and miserable before getting the swab is
> >about 4 days. The shortest time is about 5 hours, when I knew I had an
> >exposure and started feeling the symptoms. And, of course, I do wear a
> >mask when I swab now so it's been about 6 months! I'm doing well!
> >
> >How do you feel about treating UTIs in women? Let them fight the symptoms
> >and wait it out since pyelo is uncommon?
> >
> >Thanks for your a priori assessment that I am evidence based!
> >
> >Take care,
> >Amy
> >
> >
> >
> >William Gibson <[log in to unmask]> writes:
> >>Dr. Baxter,
> >> Thank you for your personal opinion, but what is the evidence to
> >>support
> >>your claim. No study has shown that people get better in 12 hours if you
> >>treat strep with an antibiotic. I am glad placebo works for you, but I
> >>don't think it's a solid foundation for the practice of medicine. I am
> >>surprised that you do.
> >>
> >>Wm Gibson MD
> >>----- Original Message -----
> >>From: "Amy Baxter" <[log in to unmask]>
> >>To: <[log in to unmask]>
> >>Sent: Thursday, June 03, 2010 9:19 AM
> >>Subject: Re: Strep--Other Considerations
> >>
> >>
> >>> 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.
> >>>
> >>> -Amy
> >>>
> >>> 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
> >>>>antibiotics?
> >>>>
> >>>>-----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
> >>>>perspectives:
> >>>>>
> >>>>>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
> >>>>performance.
> >>>>>
> >>>>>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 sure...it
> >>>>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:
> >>>>> http://listserv.brown.edu/ped-em-l.html
> >>>>>Confidentiality Notice: This e-mail message, including any
attachments,
> >>>>is for the sole use of the intended
> >>>>>recipient(s) and may contain confidential and privileged information.
> >>>>Any unauthorized review, use, disclosure or distribution is
prohibited.
> >>>>>If you are not the intended recipient, please contact the sender by
> >>>>reply e-mail and destroy all copies of the original message.
> >>>>>
> >>>>>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
> >>>
> >>>
> >>>
> >>> Amy Baxter MD
> >>> Pediatric Emergency Medicine Associates
> >>> 404 371-1190
> >>>
> >>>
> >>> 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
> >
> >
> >
> >Amy Baxter MD
> >Pediatric Emergency Medicine Associates
> >404 371-1190
> >
> >
> >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

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