Blog | Tuesday, March 31, 2015

Interpreting the new sore throat article


First, this study required the work of a large team. The main work happened in 2 places, a research microbiology laboratory and our college health clinic. They took an idea and translated it into an opportunity to collect and analyze data.

Second, the accompanying editorial (written by a friend and excellent researcher Jeffrey A. Linder, MD, MPH, FACP) raises some questions that I will work to answer. He writes that we do not have enough evidence to change practice yet. He postulates that Fusobacterium necrophorum might not actually cause pharyngitis and that linking positive polymerase chain reaction testing to the risk of supportive complications (peritonsillar abscess or the Lemierre Syndrome) lacks sufficient evidence. In this blog post I will present the evidence for our assertions.

Over the past 2 or 3 decades, some authors started calling Lemierre syndrome “the forgotten disease.” It seems that the syndrome occurred regularly in the first half of the 20th century. After the introduction of penicillin, case reports almost disappeared. With the drive to decrease antibiotic use for sore throats, and the introduction of newer antibiotics that many physicians substituted for penicillin (especially azithromycin) the syndrome seemed to increase in frequency.

Published data suggest that around 80% of the Lemierre syndrome patients have a primary infection with F. necrophorum. Danish researchers reported the best 2 epidemiologic studies of this syndrome. Their studies suggested an increasing incidence of the Lemierre syndrome over the past decade.

Recent data have shown that in the adolescent/young adult age group, F. necrophorum represents the most common bacteria in peritonsillar abscess.

Data from England and Denmark reported on the incidence of F. necrophorum in pharyngitis patients. Several studies suggested that in adolescent/young adult patients F. necrophorum caused at least as many sore throats as did group A streptococcal pharyngitis.

Our current study documents that in our college health practice we find more sore throat patients having a positive polymerase chain reaction for F. necrophorum than for group A streptococcus. We also document that their clinical signs and symptoms (using the Centor score) mirror the signs and symptoms of group A strep.

How should we act on these data? The Lemierre syndrome is devastating with an estimated 5% mortality.

Paul Sax, MD, in a current blog post, explains our position succinctly: Remember this: Patients with Lemierre's are often critically ill. They frequently require ICU care, have high spiking fevers with staggeringly high white blood cell counts, and invariably have multiple septic pulmonary emboli with potentially other metastatic sites of infection, including the brain. It's a terrifying illness. These are most commonly previously healthy high school and college-age kids, so the stakes are high. No, we don't know that treatment of severe pharyngitis “caused” by fusobacterium will prevent Lemierre's, but doesn't that make biologic sense?

As I give pharyngitis talks around the U.S., infectious disease physicians often approach me to describe their personal experiences with Lemierre syndrome patients. I believe we have a responsibility to try to prevent this syndrome. Therefore, I favor treating “sick” adolescent/young adult sore throat patients empirically with penicillin (or amoxicillin) or a cephalosporin. If they worsen, I would empirically use clindamycin.

I hope we can find a company (or more than 1) who would develop a point-of-care test for F. necrophorum. Until then we should follow Dr. Sax's advice: So let's go with the pediatricians' common-sense approach to clinical care, and make a decision about antibiotics based on that sixth sense of “is the kid really sick?” If so, go with some penicillin — especially if at the first encounter they didn't get treated, and then they come back a few days later even worse.

Or, if you prefer, listen to the guru of pharyngitis himself, Dr. Centor, and his interpretation of national guidelines:

We believe that following the American College of Physicians/Centers for Disease Control and Prevention guidelines endorsed by the American Academy of Family Physicians would decrease the risk of Lemierre syndrome in adolescents and young adults. Using these guidelines, physicians can choose to prescribe antibiotics for patients with a pharyngitis score of 3 or 4 (three or four of the following: fever, absence of cough, tender anterior cervical lymph nodes, tonsillar exudate).

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.