Written by Christopher Kelly
Feb. 24, 2015
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Christopher: Hello, and welcome to the Nourish Balance Thrive Podcast. My name is Christopher Kelly and I'm joined today by a medical director, Dr. Jaime Busch. Hi, Jaime.
Jaime: How are you, Chris?
Christopher: Good, thank you. We're actually here together in person. This is not a Skype connection or anything. We're actually here together. I wanted to talk to you today about strep throat. And the reason why is we have quite a few people emailing in asking questions about whether or not they should take antibiotics to treat a strep throat. So, normally, what has happened is they'd been to the doctor's office and the doctor suggested antibiotics.
And that person is worried that they're going to do some lasting damage to the flora, the microbiota that live, the bacteria that live inside their gut. We know that in some instances, the microbiota never really recovers or go back to how it was before after you've taken antibiotics. So there's some genuine concern there, but my initial and short answer to those people was you should do whatever your doctor tells you.
Like who am I, a computer programmer, to tell you to do anything other than what your doctor tells you? I should preface this whole conversation with the fact that although Jaime is a licensed medical doctor and she is practicing, she's only licensed to practice and treat people that she sees in person in California. And she's not seeing and treating you in person in California or in this podcast.
So this is just information. The question is then how is this information useful? And my answer to that is it allows you to make a better decision. So I wanted to talk to you about an example of that that came around. Just shortly after I graduated Computer Science, I went to work for a big tech company. It was actually Yahoo in London. And one of the senior developers once said to me that, "If God is in the details then you'd better get religion."
And that sounds kind of cryptic but what he meant by that is if you're a computer programmer and you're writing a program and some detail is important to whether or not that program is successful and efficient and correct, then you better understand the details. To give you a concrete example, I don't know if you know this but nourishbalancethrive.com is a program that I wrote, the entire website. It's not a WordPress blog. It's not some store-bought thing.
I wrote the whole thing in Python. And to do that, I didn't need to know any of the details about the computer I was sat at when I wrote that computer program. So, the MacBook Air is amazing piece of technology. I don't even know how many processes are on it and I really don't know any of the details. Now, the same is true for a lot of people right now with their medical advice.
They go to the doctor and they just take the prescription without really even knowing or understanding any of the details. And, I think, if you do know some of the details, we know you're smart people -- You're listening to this podcast, so you must be smart -- I think you can handle the details. I think, when you have them, you could a make more informed choice. So to get back to this specific example, strep throat -- Strep throat is a kind of a colloquial term. And what we really mean by that is pharyngitis that's caused by a particular type of bacteria, streptococcal.
So, Jaime, first of all, how common a problem is this? How often do you see this in practice?
Jaime: Well, I feel that many people, especially this time of year, in the fall-winter and even on to the spring months, present with sore throat. And that's a very common complaint in primary care medicine. Up to 20%, 30% of patients come in sick with coughs and colds and sore throat. It's part of the consolation of the symptoms. Now, whether or not a sore throat is caused by what's called Group A Strep, which is a certain type of bacteria that causes strep throat, that incident is a lot lower.
So those that come in -- What a sore throat is, it's the most often caused by a direct infection in the back of your throat, in an area called the pharynx. Hence, the term pharyngitis. And it's primarily caused by viruses or bacteria. But other causes can include post nasal drip, which is from an infection or allergies, could be reflux disease causing a cough, or that causes a cough and a sore throat, or just a cough itself. Constant coughing can cause sore throat.
Christopher: So what you're saying is if I come in to your office and I've got a sore throat, that doesn't necessarily mean it's strep throat, in fact, it's actually quite unlikely?
Jaime: Absolutely, Chris. It doesn't mean that at all. I see it most of the time. Group A Strep pharyngitis accounts for maybe up 15% to 25% of cases in children.
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And that's even less common in adults, 5%, 10%, maybe up to 15% in adults. Most of the times, it's caused by other agents or ideologies.
Christopher: So what are the risks? How bad is this? What are the potential complications? Is there any reason why? So normally, what happens when I get sick is I just let it run its course and that's the end of it. But it seems with strep throat, there's some potential serious consequences if it's left untreated. So what can happen?
Jaime: It is. Actual strep throat, bona fide strep throat caused by Group A Strep bacteria can lead to serious consequences and that's why you want to get it treated with an antibiotic. Now, I should preface this. These consequences or complications of Group A Strep pharyngitis are extremely rare in the United States and other developed countries. In fact, oftentimes we don't -- It's very rare for a primary care physician to even see this.
There's two major complications and one we hear of is called rheumatic fever. Again, that's very rare. The annual incident is less than one case per 100,000. But it can be caused by untreated or inadequately treated strep throat or scarlet fever. And both of those are caused by that bacterial, that Group A Strep bacteria. And this is also most common in children ages five to 15.
This can cause arthritis in large joints. It can cause subcutaneous skin nodules, skin rash, also neuromuscular involvement. But what we'd really look at as a consequence is possible permanent damage to the heart and heart valves which can subsequently lead to heart failure. There's also an interesting complication with Group A Strep bacteria that involves the kidneys. And, unfortunately, treatment with antibiotics can't always prevent this. And this is because it's immune mediated.
Your immune system makes antibodies towards your kidneys and the glomeruli, which are part of the filtration system in your kidneys and it's immune mediated damage to those.
Christopher: It sounds like an autoimmune condition.
Jaime: It does, sort of a cross-reactivity.
Christopher: Okay. So you've got some kind of primary bacterial infection and it's then leading to the immune system going wrong and then you get the autoimmunity, which is potentially not reversible.
Jaime: And it's called Group A Strep -- It's called Poststreptococcal Glomerulonephritis caused by the Group A Strep.
Christopher: Interesting. So, I guess, the next question is then: If we know this particular bacteria is really risky or really dangerous but not all sore throats are caused by this bacteria, how do you go by identifying a case that is caused by the bacteria?
Jaime: We do have testing available for that in your primary care physician's office. However, we'll tell you a lot of the diagnosis of strep throat is pretty much based on clinical presentation. What that means, there's four criteria that we have established that if you meet two or three out of four of those, it's likely that your symptoms weigh more in the direction of having a pharyngitis caused by strep.
And those are called the Centor Criteria. And there's four of them. The first one is fever. Usually, patients present with a fever. If you have a bad sore throat without a fever, it's likely not related to strep. The second part is tonsillar exudate. What that means is just sort of purulent or pus material on the tonsil, an exudate, a discharge that your clinician, your family practice doctor--
Christopher: I'll post a picture. There's some great pictures on Wikipedia.
Jaime: There are pictures. You can totally Google them. Google Image these pictures but your doctor will see those on exam as well. And then the tonsils themselves are very red and inflamed. The third one is on the front of your throat, you have lymph nodes on your neck. And if you push on them and they're sore, that's called lymphadenitis. That's another positive predictor of strep throat.
And then the last one is, and I always use this one, the absence of a cough. A lot of patients will come to me and say, "You know, my throat is killer sore. I had a fever," a wishy-washy presentation. But then I always ask them, "Do you have a cough?" And nine times out of ten they'll say, "Yes, I have a cough." So part of the Centor Criteria is an absence of the cough. So strep throat caused by the actual Group A Strep bacteria does not cause a cough.
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If you have a cough, especially bad coughs, usually your sore threat is from the cough itself or just from the virus or other bacteria that are infecting the back of your throat and your bronchi and you could have more of a presentation of bronchitis.
Christopher: This is great. Now, we've got some criteria that we can use to help identify whether or not it really is strep throat. And I'll go and put these on the website so you can go back and refer to them. It seems like then I could almost rule this out. If I think it's just a sore throat because it's been induced by cough, I could almost diagnose that for myself just by knowing that I got a really bad cough.
Jaime: Likely. Very likely. That's primary clinical diagnosis. But I mentioned we also have test that we do. A lot of physicians have what's called the rapid strep test in their offices and it's available. It takes five minutes to do. The problem with that test is it has a wishy-washy or low sensitivity rate. That rate is anywhere from 90% to 95% base.
Christopher: So what does that mean then, the specificity?
Jaime: Well, sensitivity.
Christopher: Sorry, sensitivity.
Jaime: All diagnostic tests have what's called sensitivity and specificity. So, sensitivity is basically a catch all phrase for ruling something in. So, if I swab your throat and my test had a 90% to 95% sensitivity and I swab your throat and it came back negative, Chris, there's still 5% to 10% chance that I didn't catch it, what's called a false negative. That test is falsely negative.
However, if it came back positive -- The testing in the physician's office has a very high specificity. And that's different from sensitivity. Specificity basically means if it comes back positive and if I say it has a 98%, 99% specificity and yours came back positive, there's only 1% chance or 2% that it was actually called a false positive. Does that make sense?
Christopher: To give you another example, we run H. pylori test, which comes from a stool sample in our practice Nourish Balance Thrive. It has, for the sensitivity, greater than 94% and then the specificity, which we'll talk about now, is greater than 99%. So what this means is if they come back and say, "Hey, we saw an H. pylori antigen, then you've got H. pylori."
Jaime: He's 99% right.
Christopher: Okay, yes.
Jaime: So you have about 1% or less chance of that test being what's called a false positive. If I tell you my test is 99% specific and you're coming back positive, it's pretty spot on.
Christopher: Yeah. But if you run enough tests, you're going to miss--
Jaime: You're looking at the specificity and they all came back positive, one out of 100 would be what's called a false positive. So they were really negative to begin with. This is very abstract and confusing concept. They're statistics.
Christopher: I guess the important take home is the test is not perfect.
Jaime: The important take home is that it will miss up to 5% to 10% in the clinic. So that's why. This is what physicians have to do. We have to weigh the inconvenience of having to then send that for culture. What a culture means is we re-swab your throat in the office and we send it to a lab. And the lab will take that sample and grow it in their lab and grow out the bacteria and see actually what is growing.
That's a little more sensitive. It will pick up a lot more tests. And if it came back and it's almost 100% specific, if it tested positive in the lab, it's pretty positive. But there's a delay. There's a two to three day delay on that. So what's to do with the patient?
Christopher: So, what do you in the patient in the meantime?
Jaime: What we usually do, as physicians, and what I do -- A lot of this is based on experience. You've seen this day in and day out. I go back to the criteria. Are they coughing? How does the back of their throat look? Do they have the tonsillar exudates or the redness? How sore their throat are? Are there lymph nodes on the front of their necks or do they have a fever?
It's more of a clinical diagnosis. If they have all that, and my test tested negative in the office, I say it's probably a false negative. They probably really are positive. I would go ahead and send it to the lab. But then I would probably start my patient on antibiotic because I don't want to delay two to three days.
Christopher: Okay.
Jaime: So, again, it's mostly a clinical diagnosis.
Christopher: Is it very specific antibiotic you use or is it--
Jaime: It is. It is quite simple. It's penicillin.
Christopher: But what happens? I can ask this question. This is kind of weird to me. I'm allergic to penicillin. What happens then?
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Jaime: There are substitutes. There are substitutes for that so we can indeed treat you.
Christopher: Okay.
Jaime: But again, I don't advocate for everybody to be on antibiotics if you don't need it. We have two major problems. One is altering our own health, our own gut flora on it. It can cause GI distress. A lot of things that a lot of people don't know about that they can be toxic. They're killing bacteria. They kill the good bacteria too. So sometimes they're not as specific as we like them to be.
And then the second thing is in this country and really the world, we're having an issue with antibiotic resistance, which is getting to be pretty serious because when we do need our antibiotics for certain types of diseases a lot of these bacteria are mutating and becoming resistant. And that's because of overuse of antibiotics or inappropriate use of antibiotics. So it is becoming an issue. I don't tend to push antibiotics on anyone unless I really feel necessary. And if someone is diagnosed with strep throat then, yes, it quite is necessary.
Christopher: We actually see that. I talked about the bio health test just a moment ago for H. pylori but we're also running another type of test, done by Genova Diagnostics, and it's the 2205 stool test. And it's recently being upgraded. And one of the nice features that appear when it was upgraded is they actually go on and they do a stool culture where they look to see -- They actually test with antimicrobial agents and they look to see which of them are effective.
So what they can tell you from this is which antibiotics are likely to work for you against the bacteria that they've actually found on the culture. I think this is pretty cool. Like we can actually finally start to quantify some of these things that we know are issues but we can't quite get a handle on. And I know as well from talking to -- I'm currently taking part in a study that's organized by the University of San Francisco and they're looking at the effects on the microbiota from antibiotics.
And there's three arms of this test. The first arm is a clinical trial, I should say. So the first arm is like that people don't do anything. There's no perturbation at all. They're not going to do anything to these people. And then in the second arm, this is me, they're going to give me something called go lightly that you might have figured out what that's like.
Jaime: That cleans you out, Chris.
Christopher: Right. So what's going to happen is it will clean me out but it's not selective. This is the important point. So then they're going to give the third arm, an antibiotic, and we all know that not all of the bacteria will be killed. And you don't really know which bacteria is going to be selected and which is going to be left behind. And some of the bacteria that are left behind, they could be good, so you might see an improvement in the gut microbiota.
Or they might be bad. You might be just left with the pathogens. And then you've got problems. We already talked about a potential connection with autoimmunity there that's been like the catalyst as an infection. So this is obviously not good. But clearly, I think this is one of these situations where if the test is done carefully, which I'm sure it always is, the antibiotics are certainly justified. And so my initial recommendation to do whatever the hell that your doctor tells you is right here, I think, that you should.
Jaime: To a point. But I always like to tell and I will tell you in the conventional modern medicine, it's a very high, fast pace field, very busy, doctors are typically seeing up to ten, 14 patients per half day. So we're pretty rushed.
Christopher: So it's not fair, isn't it?
Jaime: Yeah. Well, with the pressures from a multitude of factors that cause us to see so many patients and be so rush but I've seen many physicians inappropriately prescribe antibiotics just to sort of rush patients in and out. And then part of it is the patients too are quite demanding at times and they would want an antibiotic and they're not going to leave or feel better until they have that antibiotic. So it's up to the physician to educate their patients on all of this stuff. And a lot of us are time crunching and we don't quite have it.
So I encourage all of my patients to be educated themselves and read about it. And every time I diagnose something, I write it down for them and tell them go to this site. Good sites are like Mayo Clinic, CDC. Make sure you go to reputable sites when you are doing your research. But educate yourself on the diagnosis and the treatment and if you're on any kind of medication or antibiotic, know what's it or and know why you're taking it. Plenty of people don't seem to understand that.
Christopher: Oh, yeah. We did a presentation at a local police station recently and a couple of the guys said, "Well, I'm taking a ton of stuff." Like six or seven prescriptions and didn't know what any of them, what they were.
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Jaime: They have no idea. I see it all the time. So I think it's really important and very empowering to know about your own health and to have an educational conversation with your doctor. And if you go into your doctor armed with that information, not with the whole stack of stuff that you Google and print it off from Wikipedia. Doctors don't appreciate that. But if you go in and say, "Here are my symptoms. I was reading about this. Do you think it's that?"
And you would have a very educational conversation with your physician and, I think, they will welcome that because they would welcome educating you more on what they think it is. And you can be involved in your own diagnosis and treatment.
Christopher: Yeah, that's a really important point. And I've certainly been guilty of not doing this and that's empathizing with your doctor. So I was afflicted with some problems that doctors don't really have any good, at least the type that you're likely to meet in your primary care practice that take your health insurance, they just don't have good answers to the types of problems that I had.
And in that instance, they can't help you. But that doesn't mean that no one can help you. And it also doesn't mean, and more importantly, that that doctor isn't useful to you for other reasons. And so when you approach them, you need to empathize, you need to think about their day. So their day is divided into 15 minute time slots and you've just turned up with all this stuff printed out from Wikipedia. I mean, how can they possibly process all that and help you in 15 minutes with all of that?
Don't upset them and don't make -- When I went through all of this, I fired a bunch of doctors and eventually got fired by a doctor because I failed to empathize with his day. He said, "I'm not going to order some tests I don't know how to interpret. Why are you asking me to do that?" Yeah, understand that the doctor are still, even if they can't help you for one particular thing, that doesn't mean they can't help you for anything and nurture that relationship and keep it on the right side of bad.
One final question I have for you is: Which is the bias? Which do you see more of? Do you see more of people that don't want to take the antibiotics because they're worried about like the long term effects? Or would you see more of the people that are saying, "Give me the antibiotics," even though you know it's probably not strep b?
Jaime: Honestly, more and more, I'm seeing a lot of people that don't want to be on antibiotics. And not just antibiotics but medicine in general. If I had diagnosed diabetes or pre-diabetes, I have a lot of patients with pre-diabetes or high cholesterol and I tell them about the lifestyle changes, which I think will work far more than any medicine. Most people I encounter do not want to start medicine.
Christopher: Which is fine.
Jaime: Yeah, which is fine.
Christopher: But you need to do something about it.
Jaime: Exactly. So empowering them to make the change is a little more challenging. Most people don't want to. I do have a lot of patients that, based on their previous doctor, "I get this every year," "I've had this in the past. It's always responded to a Z-Pack or amoxicillin. I always have this. I know what it is. I know it's my typical sinus infection." And I have to try to convince them to give it the college try and wait it out another week. I'm always trying to do that.
But we do get patients that are pretty set based on their past experience and their previous physician that just wanted to rush them out of the office and give them what's called a Z-Pak, which is a five-day course of an antibiotic that most doctors just give for any cough just to kind of rush patients in and out. Yeah, physicians tend to be in a difficult spot because we know what's right and we know all about the antibiotic resistance and we know all about the criteria and the recommendation guidelines in regard to prescribing antibiotics and sore throat or bronchitis and sinusitis.
We know all about this. But we do get pressure from patients to prescribe. It's definitely a challenging job but I have been finding those patients are leaning away from medicine, which is a really positive thing.
Christopher: Like we said, you still need to do something about it. You can't just like stop taking the statin and keep eating whatever it was.
Jaime: Exactly.
Christopher: Or keep working the same job or being under the same or whatever it was that caused the problem in the first place. You need to change those things, not just stop taking the medicines.
Jaime: So what I will recommend in conclusion is to arm yourself with a power and with information as you go to your doctor. If you're coming in with a sore ear, an earache or a sore throat or what you think is a sinus infection, read about it. Or even a cough. A lot of people think they need an antibiotic if they had a five-day cough.
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So read about it. Read about bronchitis. And then ask your doctor. If they want to just write you a prescription, ask them, "Doc, do you think I really need an antibiotic? What happens if I won't take this? What do you think? Do you think this is a virus?" And have this engaging conversation with your physician. I think they would be very open to it because you've just made their life a little bit easier if they don't have to convince you that you don't need an antibiotic, if you're actually interested. And then have them, if they want to give you an antibiotic, have them give that rationale.
Christopher: Well, this has been great, really useful. I've certainly learned something. I'm discovering the dynamic of interviewing someone in person. It's very different from you only get to see someone on Skype and--
Jaime: Yes. We'll have to do this more often.
Christopher: Yeah. You don't make eye contact. And you don't know when the next person is going to speak and all of that. So, yeah, very different. Hopefully, you enjoyed this. And maybe you've got some other questions, a very specific topic that you would like answered and I'm more than happy to dive into that and then get Jaime involved to see what she thinks.
Jaime: Yes. We'll probably be doing more medical based series, short podcast questions like this. This is a good thing.
Christopher: This is our Ask a Doctor. Take advantage of it. It's a lot cheaper than your health insurance, I would say that.
Jaime: All right.
Christopher: Okay. Thanks so much.
Jaime: Bye then.
Christopher: Bye.
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