I have practiced medicine for over 18 years and have gotten a lot of CMEs over that time. The lectures I enjoy most tend to be those exposing the myths of modern medical practice. You know the ones that I mean: These are the lectures comparing some common medical practice with the literature only to find that the practice doesn’t work—accepted wisdom about its efficacy is a myth. Just prior to its lamentable demise, the Western Journal of Medicine had a regular series devoted to debunking medical myths.

Myth busting like this is part of the overall movement toward evidence-based medicine, which, in a nutshell, states that we should compare everything we do as doctors with the scientific evidence of its effectiveness. When we do that, we will find there is a solid base in the evidence for only some of the things we do. Some of our practices have inadequate support in research—nobody really knows whether they are truly effective. And some of what we do is flat out contradicted by the evidence. Every year, important research emerges that should make us change the way we practice medicine. Too often, however, we do not change.

We all know doctors who seem frozen in time; practicing medicine the way it was taught to them in medical school and residency. We ask ourselves, “Why is he still doing that?” However, that doctor is most of us. If we critically compare many of our habits with the medical literature, we invariably will find that we ourselves have habits we should abandon.

Failure to change practice based on new findings has been identified by many sources as a major problem with modern medicine. There is a gap, sometimes of many years, between what is known and what is practiced. Over the years, some information in medicine’s knowledge base is verified, and some is refuted. Whenever a new “fact” is added to the overall medical knowledge base through good and repeated research, it usually takes many years until that knowledge is incorporated into most physicians’ practice."

Case in Point
Even a casual review of medical textbooks and the literature will bring to light several well-demonstrated medical facts that are not widely reflected in the practices of U.S. physicians.

One area getting a lot of press is the overuse of antibiotics. We doctors still commonly prescribe antibiotics (and often very expensive antibiotics) for viral illnesses such as pharyngitis, bronchitis and sinusitis despite the enormous amount of literature condemning the practice.

We all have heard about the emergence of resistant bacteria as a consequence of our national overprescription of antibiotics. We don’t so often hear of another downside to prescribing unneeded antibiotics—it is expensive. In fact, most evidence-based medicine principles are like that—if you adopt them, you will save money. What could be better? We provide better medical care to our patients and save money to boot!

One great example is evidence-based treatment of pharyngitis, the infamous “sore throat.” The subject of literally hundreds of published articles, this seems to be one of the single most studied topics in medicine. Fortunately, the Centers for Disease Control and Prevention in Atlanta has published an excellent review article along with recommendations that can serve as a basis for your facility’s “sore throat protocol.” Titled “Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults,” the article was published March 20, 2001, in the Annals of Internal Medicine, along with similar guidelines for the treatment of sinusitis and bronchitis. (The articles are available via the CDC Web site at www.cdc.gov/drugresistance/community/technical.htm.)

In the pharyngitis article, the CDC makes the point that only about 10% of sore throat cases are caused by group A beta-hemolytic streptococcus (the so-called “strep throat”). Almost all of the remaining 90% of cases are viral in origin. Despite this, 75% of adults who present to a doctor with a sore throat will be prescribed antibiotics! What is the rate of antibiotic prescriptions for sore throat at your facility? It would be worth the effort to pull the last 100 charts where the chief complaint was sore throat and see how many of these patients received antibiotics.

Recommended Practice
The CDC recommends that antibiotics be limited to those patients who are most likely to have strep throat based on four easily evaluated clinical findings: (1) tonsillar exudates, (2) tender anterior cervical lymph nodes, (3) fever and (4) absence of cough. You then use these four criteria to determine who gets antibiotics in one of the following ways:

1. If the patient has 0, 1 or 2 of the criteria, no antibiotics should be prescribed. If a patient has 3 or 4 criteria, then antibiotic treatment may be used. I prefer this strategy at my jail because it does not require the use of rapid strep screens, which cost $5 to $10 each.

2. If you prefer to use the rapid strep test, the CDC recommends no treatment for patients with 0 or 1 criterion, and rapid strep testing for those with 2, 3 or 4 criteria. You then treat those where the rapid strep test comes back positive.

The CDC recommends throat cultures not be routinely performed. This is important because many lab facilities routinely follow up all rapid strep screens, whether positive or negative, with a $60 culture. Throat cultures should be reserved for special circumstances, such as tracking epidemic outbreaks of streptococcal disease, or if there is a suspicion of another bacterial pathogen, such as gonococcus.

Finally, the antibiotic preferred by the CDC for the treatment of strep throat is plain penicillin. Not amoxicillin. Not Keflex. Definitely not Augmentin! If the patient is penicillin allergic, erythromycin should be used instead. This point is important enough to repeat: Do not use expensive, broad-spectrum antibiotics to treat routine strep throat.

These guidelines do not apply to complicated patients, such as those who are immunocompromised or those with other significant medical problems, such as COPD or a history of rheumatic fever. The guidelines also assume the practitioner will carefully exclude other serious throat disorders, such as peritonsillar abscesses or epiglottitis. Still, at my jail, the guidelines apply to over 95% of the patients who present to our medical clinic with sore throat.

A Typical Patient
Here is how the guidelines apply to a typical case. A healthy 35-year-old male presents to the jail medical clinic with a sore throat. His temperature is 97.6 F. He has large red tonsils but no exudate. He has 2+ tender anterior lymphadenopathy. He has been coughing frequently. Physical exam shows no evidence of abscess or other complications. This patient has only one of the CDC’s four clinical criteria. According to the CDC guidelines, he should not have a rapid strep screen performed nor a prescription for antibiotics. Instead, he would be treated symptomatically with acetaminophen, increased fluids and rest.

I encourage everyone to read the CDC report. It is concise, well written and authoritative. The four basic clinical criteria are easy to incorporate into a clinical decision model or a flow chart for your facility. If your facility adopts these guidelines, the quality and consistency of your medical care for sore throat will improve and your medical costs will fall.