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Healthcare Providers’ Resistance to Antibiotics and a Very Sore Throat

One of my colleagues at Revolution Health has a daughter who is a freshman in college (we’ll call her Julie). Julie has been struggling with a very sore throat for many months, and her mom would occasionally ask my opinion about her care.

Julie initially believed that she had a viral throat infection and tried to wait it out. Several weeks later the pain was quite severe and worsening instead of improving, so she sought help at the student health service at her university. The nurse reassured her and told her to wait a little bit longer and come back in a couple of weeks if things weren’t improving.

Two weeks later Julie was back, and was offered a monospot test (which was negative). The nurse practitioner gave her some samples of Keflex to treat her presumed strep throat, and was told to return in 2 weeks if her symptoms hadn’t resolved. Julie’s mom asked me if I thought that was ok, and I mentioned that drug resistance was not uncommon to Keflex, but that it was really cheap. I explained that Julie’s throat had been sore for an awfully long time, and that if the Keflex didn’t improve her symptoms within a few days, she might want to try something stronger.

Guess what? A week later Julie went back to the student health service with continued symptoms, and their response was to continue the Keflex for a full 10 days. Julie asked if a different antibiotic might be appropriate, and they simply replied that the health service only carried Keflex.

Julie completed the full course of antibiotics with no improvement. She called her mom to ask what she might do next and I suggested that she consider seeing a physician about an antibiotic with a lower resistance profile (like azithromycin). She was unable to get an appointment for a couple of weeks. The student health service nurse said that Julie’s throat did not appear concerning.

As it happened, Julie began having difficulty swallowing, was unable to sleep because of her throat pain, and had a low grade fever. I worried about a peritonsillar abscess (pus trapped in the deep tissues of the throat) and counseled Julie’s mom to get her to a physician right away. Julie flew to DC to be with her mom for the weekend, and was able to get an appointment with a primary care physician who gave her some azithromycin and steroids and said that there did not appear to be any visible signs of a peritonsillar abscess.

Again, Julie’s pain continued unabated. Her throat became even more swollen – and at that point I encouraged them to go to the ER to rule out an abscess. Julie was seen by an affable young ER physician who promptly ordered a CT scan of her neck. Several hours later the diagnosis was confirmed: Julie had pus trapped in the deep recesses of her throat. The ER doc numbed up the tonsil area and inserted a needle into the pus and pulled out several cc’s of thick green goo.

Man I wish I could have been there. (I know that’s a weird response, but docs LOVE pus.)

As I thought about this case, I wondered if we’ve gone too far in withholding antibiotics from deserving patients in our quest to reduce resistant bacterial strains. For every Julie there’s probably 100 others receiving (quite inappropriately) azithromycin for a viral throat infection… but Julie’s case may represent a new kind of provider problem: their own resistance to antibiotics.This post originally appeared on Dr. Val’s blog at

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5 Responses to “Healthcare Providers’ Resistance to Antibiotics and a Very Sore Throat”

  1. Dr. Scherger says:

    This is simply bad primary care.  For a primary sore throat, antibiotics are standard treatment due to the high rate of Strep.  The use of Keflex, even when it was not working, is simply bad treatment.  You suggest our problem may be underuse of antibiotics.  I think this case shows misuse, and errors in thinking, all too common in medicine.

  2. ValJonesMD says:

    Good point, Joe. I probably didn’t do the best job of capturing the reasoning behind all the hemming and hawing in getting this woman some proper antibiotics – the nurses were told not to give antibiotics if at all possible (to prevent antibiotic resistance) and they did this poor patient a disservice. Of course overuse is generally our main problem… but occasionally we see the flip side.

  3. DrDavid says:

    Val,  I think your post is excellent, but there are a couple of points to make.  Joe made one of them (Keflex for strep throat?).  But… given her peritonsillar abscess, the I&D part was also necessary, and simply using the right antibiotic would have been insufficient care.  So what “Julie” really needed was, as Joe pointed out, competent care.  It’s disappointing that someone who works at a university health service, who presumably sees a LOT of kids with sore throats, would not recognize that a sore throat lasting that long almost HAD to be something more than “strep” resistant to the Keflex.  College kids deserve better than that.  “Julie” is lucky her mother has a friend like you to subtly intervene and get her the care she needed.

  4. Ian Furst says:

    Agree with the missed diagnosis but someone along the way must have looked at her throat and not seen anything too far out of the ordinary.  Tonsillitis is not rare and would have preceeded the peritonsillar abscess.  Regardless, keflex shouldn’t have been the first choice.  That being said, wrong antibiotic and wrong dose is amazingly common for deep neck infections (erythro is a common one despite all of the anaerobes classic to these infections).  Every spring and fall I see many that have been undertreated and I think Val’s point is valid. Practitioners shy away from anything any more broad spectrum than amox/keflex/erythro.   

    Once you see the infection hit it hard with the the narrowest spectrum antibiotic that you know covers the infection.  When it gets to the airway I hit it especially hard and usually with multiple agents to cover anaerobes and emerging clinda-resistant strains.  Resistance is one thing but risking the airway is quite another.

  5. ValJonesMD says:

    I guess I was also theorizing that the infection wouldn’t have become an abscess if the right antibiotic had been given earlier. It really surprised me that she had the sore throat for so long before she got any antibiotics, and before she got the broader spectrum variety. I totally understand waiting for a week or so for a sore throat to go away… but weeks upon weeks (and the mono spot was negative)? I feel really frustrated by the provider apathy shown to this young woman – why wouldn’t anyone take her complaint seriously? Argh! Thanks for the comments, Ian and Dr. David! I have a nice photo of the pus in a syringe… I wish my blog could embed photos. Maybe next month…

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