ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Tuesday, March 26, 1996 TAG: 9603260021
SECTION: EXTRA PAGE: 3 EDITION: METRO
COLUMN: PERSONAL HEALTH|
SOURCE: JANE BRODY
Each winter more and more American families are plagued by recurrent strep throats that ping-pong among the children and their parents and do not quit until school finishes for the summer. Unlike the common cold, a far more familiar family plague during the school year, strep throat is much more than a pesky illness. It is debilitating, costly and dangerous.
In addition to having a throat too sore to swallow water comfortably, the victims of strep throat are likely to feel sick all over. Parents, even those who remain healthy, often lose days from work to stay home with their ailing children.
The obligatory visit to the doctor, throat culture and antibiotic prescription can easily cost more than $100. And failure to properly diagnose and adequately treat each and every case of strep throat can sometimes result in a very serious, even life-threatening complication: rheumatic fever.
Rheumatic fever was once nearly eradicated by the proper treatment of strep throat with penicillin, but the last 10 years have seen a resurgence of this deadly but preventable disease in cities like New York, Salt Lake City, and Pittsburgh, and at a few military bases.
Among the reasons for recurrent strep infections and the resurgence of rheumatic fever, experts say, is a failure to use enough of the right antibiotic to eradicate the bacterium, beta-hemolytic group A streptococcus, that causes strep throats.
This can result in simmering and sometimes symptomless infections that may cause hidden damage or flare up again and again as a sore throat or spread to someone else. Contributing to the problem is an apparent decline in the ability of the standard penicillin regimen to eradicate the bacteria completely.
Dr. Joseph Appel, a pediatrician in Kingston, N.Y., said that ``5 percent to 10 percent of children have recurrent strep throats, three recurrences is not rare and a ping-ponging effect in families is quite common.''
A mother may bring in one child, then a second child a few days later, then she herself gets sick. Two weeks later, the first child is sick again. He said that the family dog might even be involved in the cycle in rare cases. The dog can act as a carrier of strep bacteria, and until the dog is treated, various family members may continue to get sick. Veterinarians who test a dog should be aware that in such cases the bacteria live in the dog's anus rather than the throat.
Most sore throats are caused by viruses and require only symptomatic treatment: plenty of fluids, a pain reliever and rest. Viral sore throats typically occur with a cold and may be associated with a low-grade fever (especially in children), malaise, loss of appetite and discomfort upon swallowing. No antibiotic is of any use and none should be taken.
Strep throat, a bacterial infection that rarely occurs before the age of 2, often begins in children with a headache, abdominal pain, vomiting and a fever that may soar to 104 degrees. The throat becomes sore within hours of the first symptoms, with pain that can range from mild irritation to soreness so severe that even swallowing water is difficult.
Strep throats are most common among young school-age children, but people of all ages can and do become infected if exposed to a strain of the bacterium to which they are susceptible.
But it is not possible to tell if the infection is strep without a medical examination and laboratory test for the bacterium. Dr. Gary Ruoff, a family practitioner and researcher at the Westside Family Medical Center in Kalamazoo, Mich., and a clinical professor at Michigan State University College of Human Medicine in Lansing, says that patients with strep throat typically have enlarged lymph nodes (glands) in the neck, swollen tonsils, redness in the back of the throat, aches and pains in their muscles and probably fever.
But to be certain the infection is bacterial, a laboratory test is needed. A culture of matter swabbed from the tonsils is the time-honored test, but it takes 24 to 48 hours to know if strep bacteria grew in the laboratory dish.
If a patient is very ill or likely to expose others, doctors often start antibiotics right away and stop them if the throat culture is negative. Meanwhile, the doctor may use a less reliable rapid antigen-detection test, also done after a swab of the tonsils, that can reveal the presence of strep in two to three minutes, Appel said.
Ruoff and Dr. Martha Lepow, a specialist in pediatric infectious diseases and chairman of pediatrics at Albany Medical College, said a failure to take the full antibiotic prescription was the main cause of treatment failure and recurrences.
Older antibiotics like penicillin, which remains a preferred treatment against strep, must be taken three times a day for 10 days. When patients begin to feel better after about 48 hours, treatment laxity creeps in: doses are forgotten or, by day five or so, the entire regimen is stopped. For patients allergic to penicillin, the doctor may prescribe erythromycin, which can cause stomach and intestinal upset and prompt people to stop taking the antibiotic as soon as they feel well.
But when the antibiotic regimen is not completed, some bacteria - ``the toughest ones,'' Ruoff remarked - remain alive and can cause a recurrence or can infect someone else. Each failure to complete treatment thus favors the survival of bacteria best able to resist the antibiotic.
Appel said that strep bacteria have become ``relatively resistant'' to penicillin. In the 1940s an infection could be eradicated with just 5,000 units of penicillin, but it now takes 1 million units, he explained. Even then, 12 percent to 17 percent of infections are not fully eradicated, Ruoff said.
There are now newer antibiotic alternatives to penicillin that involve fewer daily doses and even shorter treatment periods. They include antibiotics called cephalosporins, some of which involve doses only twice a day for five days.
Although these drugs are much more expensive than penicillin, costing from $25 to $90 to treat one infection, as against only $5 or $6 for penicillin, Ruoff maintains they are worth it if they improve patient compliance and reduce the likelihood of recurrence, which results in a far more costly doctor visit, throat culture and another round of antibiotics.
Yet another problem may contribute to treatment failure, Lepow suggested. Some people harbor in their mouths or throats bacteria that produce an enzyme, beta-lactamase, that can inactivate penicillin. To get around this problem, doctors sometimes prescribe a combination drug, amoxicillin plus clavulanate (Augmentin), that can knock out the interference.
For children plagued by recurrent strep infections, Lepow said that winter-long preventive treatment with a single daily dose of penicillin could be helpful and did not create antibiotic-resistant bacteria. Apparently the single dose is enough to stop bacterial growth before resistant strains can develop.
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