Home score for strep throat in adults could avoid unnecessary doctor visits

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Telling the difference between run-of-the-mill sore throat caused by a virus, which doesn’t require medication, from strep throat caused by a bacterium, which should be treated with antibiotics, is a tricky thing at any age.

As a mom to three school-aged kids, I have schlepped off to the pediatrician many times to check out a variety of colds, fevers, and sore throats. Many of these appointments included the drama and trauma of the much dreaded (at our house) throat culture. Until recently, the results were always negative.

I was taken aback when our 7 year old actually had strep throat. In the middle of summer.  Twice. The first time involved a very sore throat, fever, and what I thought was a heat rash (it was 90 degrees all that week), that turned out to be the classic rash associated with strep. The second time, we saw similar symptoms, minus the rash. When the next sore throat rolled around, I was convinced it was strep—similar symptoms, plus some little white spots in the back of his throat. Rapid test: negative. Culture: negative.

Huh.

It can be just as tricky in adults. Current guidelines say there is little benefit for throat swabs for most adults, and they should be limited to high-risk adults. How do you know if you’re at high or low risk? One way is to visit your doctor. She or he will evaluate your symptoms and medical history and do an exam. Based on those assessments, your doctor will come up with a clinical score. If the score says you are at low risk, neither a throat culture nor an antibiotic is required. If you are at high risk, the throat culture is a good idea.

In tomorrow’s Annals of Internal Medicine, physicians from Harvard Medical School, MIT, and the Skaggs School of Pharmacy in California described an “at home” scoring approach that could save folks a trip to the doctor for what would most likely turn out to be a garden variety sore throat.

Here is how it would work. You have just developed a sore throat. You call your doctor’s office and answer a number of questions—for example, do you have a cough or are you running a fever. Your score is then calculated by a formula that accounts for the answers to those questions, your age, and the percentage of people in your area who have tested positive for strep within the last two weeks. If your score is high, then head to your doctor’s office. If it indicates that you are unlikely to have strep, then there is little need for you to rush in for an exam or throat culture. Fluids, rest, and pain relief are the first orders of business. If your symptoms persist or get worse, then you would need to see your doctor.

“We wanted to combine information on how prevalent the infection is in the community, what we call biosurveillance, with two specific patient-reported symptoms in order to identify people who are at such low risk for strep that they are unlikely to be tested even if they do seek care,” said Dr. Andrew Fine, the study’s lead author who is also an attending physician in the emergency department at Boston Children’s Hospital and Assistant Professor of Pediatrics at Harvard Medical School.

This approach could certainly save physicians and patients the time and expense of unnecessary visits to the doctor for a non-strep sore throat. The researchers estimate that use of this kind of score could prevent 230,000 office visits in the United States each year and keep 8,500 men and women from getting antibiotics they don’t need.

There are a few drawbacks to the home score. First, data on how many people have tested positive for strep may or may not be available in your area. Second, this kind of testing would likely miss a few cases of strep throat. However the chances of getting very ill very quickly from strep are small. With appropriate follow up for continued symptoms, it is unlikely that a missed case of strep would lead to severe complications. Third, if this system were in place, it is possible that over time, fewer folks would get tested which might skew how prevalent strep actually is in the area.

In theory, the score could be bundled into an app, avoiding the need for a call to the doctor’s office.

Dr. Kenneth Mandl, professor of medicine at Harvard Medical School and senior associate in medicine at Boston Children’s Hospital is one of the study authors. He points out how important the ability to do biosurveillance is to making a score like this work. “The basic idea is that if a lot of people around you have strep, you’re more likely to get it,” says Dr. Mandl. “This information is so powerful that if you know that strep ‘is going around’ it only takes a few additional facts from a person to come up with a reasonable risk assessment—without that person ever walking into a doctor’s office or clinic.”

Keep in mind that the home score was designed with adults in mind, and won’t cut back on trips to the pediatrician for kids. The American Academy of Pediatrics recommends that all children under age 15 who have a sore throat get tested for strep.

A home score for adults would reduce urgent or emergency visits, save time, dollars, and potentially unnecessary antibiotic use. One for kids would be even better.