Should We Treat Sore Throats With Antibiotics?

How many of us have called our doctor with a scratchy throat, mildly swollen glands, congestion and overall malaise and requested an antibiotic?   “I know my body best and if I take an antibiotic I knock it out quickly.” is a common refrain.

In most cases, sore throats are due to viruses. Fewer than 10% of sore throats are caused by bacterial Group A streptococcus.  Antibiotics such as a Z-Pack (Zithromax), Penicillin or Ampicillin do not kill viruses.  If by chance a patient has a sore throat and an upper respiratory tract infection, the length of illness before recovery averages 4-7 days with or without antibiotics -whether strep is present or not.

How then did the throat culture and use of antibiotics begin and what is its rational? In the 1940’s and 1950’s when antibiotics were being introduced to the public it was determined that streptococcus pyogenes was the cause of Rheumatic Fever.  Researchers found that by administering antibiotics to patients with a strep throat they could reduce the rate of acute Rheumatic Fever from 2% to 1% (notice that even with appropriate antibiotic use we cannot prevent all the cases of Rheumatic Fever).

Applying this data in 2011 we find that there is about 1 case of Rheumatic Fever in the United States per 1 million cultured strep throats. In other words, we must prescribe one million prescriptions for antibiotics for sore throat to prevent one case of Rheumatic Fever. In turn, these antibiotics may cause 2,400 cases of allergic reactions, 50,000 cases of diarrhea and an estimated 100, 000 skin rashes.  It doesn’t make sense.

In a recent editorial article in MedPage, an online periodical supported by the University Of Pennsylvania School Of Medicine, George Lundberg M.D. presented a cogent case against throat culture use and antibiotics in sore throats and bronchitis. He suggested that “physicians should not prescribe antibiotics for sore throats….  They don’t help. They often hurt. First, do no harm!”

As an internist dealing with adult patients I am not seeing the groups most likely to catch a strep throat which is young children 2-7 years of age and their caregivers.  If patients present with fever, exudative tonsillitis and pharyngitis with large swollen cervical lymph nodes I will still culture them.  I will treat based on their immune status, general health and risk of having a significant bacterial infection. If I choose to prescribe an antibiotic I will make an adjustment based on the culture results.

Honey May Be Effective at Killing Bacteria and Thwarting Antibiotic Resistance

I have on many occasions advised my patient’s ill with an upper respiratory infection and a cough to try some tea and honey. The recommendation is based on family suggestions bridging generations plus practical experience in noting its therapeutic effect when I have a cold and cough.  Of course in today’s world of randomized double blinded objective research studies it is nice to have some evidence to back the recommendation up.

Pri-Med released a summary of a study done at the University of Wales Institute Cardiff which shows the benefits of Manuka honey.  The honey is made from the nectar collected by bees from the Manuka tree in New Zealand. This honey apparently can hamper the ability of pathogenic streptococci and pseudomonas from attaching to tissue. This is an essential step in the initiation of acute infections.

Lead author Rose Cooper additionally pointed out that Manuka honey was effective at making Methicillin Resistant Staph Aureus “more susceptible to the antibiotic Oxacillin.” Methicillin resistant staph aureus is resistant to drugs like Methicillin and Oxacillin. They do not improve or cure the infection. If you add honey, the infections are now showing a response to Oxacillin .

This is very clearly early data with more studies needed. It will not prevent me from continuing to extol the virtues of tea and honey, as well as chicken soup, as part of the treatment of a viral or bacterial upper respiratory infection.