Blog | Monday, October 29, 2018

My approach to acute pharyngitis 2018

First, we must define acute pharyngitis – no more than 3-5 days of symptoms.

Second, we should understand that pre-adolescent pharyngitis has major differences form adolescent/you adult pharyngitis. (Mitchell, M. S., Sorrentino, A., & Centor, R. M. (2011). Adolescent pharyngitis: a review of bacterial causes. Clinical Pediatrics, 50(12), 1091–1095. ) Here are the differences:
• Pre-adolescent pharyngitis really is group A strep vs viral
• Adolescent pharyngitis has a much broader differential – GAS, Group C/G strep, Fusobacterium necrophorum, infectious mononucleosis, acute HIV
• Antibiotics decrease duration of symptoms in adolescents but not pre-adolescents (Zwart, S., Sachs, A. P., Ruijs, G. J., Gubbels, J. W., Hoes, A. W., & de Melker, R. A. (2000). Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults. BMJ, 320(7228), 150–154. and (Zwart, S., Rovers, M. M., de Melker, R. A., & Hoes, A. W. (2003). Penicillin for acute sore throat in children: randomised, double blind trial. BMJ, 327(7427), 1324–1320.

Current guidelines for children are logical. Current guidelines for adolescent/adults follow from an assumption that I am happy to argue against.

Third, all guidelines recommend neither testing nor treating Centor (or McIsaac modified) scores of 0 or 1. The pre-test probabilities are very low and most positive tests are therefore false positives. Unfortunately many urgent care centers and emergency departments perform a rapid strep test prior to either a physician or nurse practitioner or physician assistant spending 3-5 minutes doing a quick history and exam. Testing wastes resources in 40-50% of patients presenting with a sore throat complaint and leads to unnecessary antibiotics. This is the biggest mistake that I see!

The controversy for adolescents/adults with pharyngitis and scores of 2-4 involves the concept of lack of proof.

Why treat pharyngitis with antibiotics? There are 5 potential reasons:
1. Prevent spread – untreated group A strep and group C/G strep can lead to infection in contacts. We have no data for Fusobacterium necrophorum
2. Decrease duration of symptoms – in adults with scores of 3 or 4, Zwart found that both group A strep and group C/G strep had decreased symptom duration. Again we do not know for Fusobacterium necrophorum
3. Prevent non-suppurative complications – antibiotics decrease the risk of acute rheumatic fever for group A. We are not sure about group C/G (although it is likely since those bacteria can also cause ARF). We do not believe that Fusobacterium necrophorumcauses any non-suppurative complications
4. Prevent suppurative complications – the Cochrane collaboration found that antibiotics decrease peritonsillar abscess regardless of pharyngitis etiology. My big concern is Lemierre syndrome. We have no PROOF that timely antibiotics will prevent the syndrome, but we must remember that lack of proof does not equal proof against that hypothesis. Many who study Fusobacterium necrophorum pharyngitis believe that appropriate antibiotics would decrease the probability of this severe complication. I believe Lemierre syndrome is the most important reason to treat adolescent/adult pharyngitis (Centor, R. M. (2009). Expand the pharyngitis paradigm for adolescents and young adults. Annals of Internal Medicine, 151(11), 812–815.
5. Prevent death from streptococcal shock syndrome – very rare

Therefore I would give penicillin, amoxicillin or clindamycin (if true penicillin allergy) to patients with scores of 3 or 4 and some 2s (clinical judgement on how sick they look). Unpublished data suggest that tonsillar exudates actually are both a predictor of empiric antibiotics and significant infection.

Please, please never use macrolides for adolescent/adult pharyngitis. They do not cover Fusobacterium necrophorum. While we do not have full proof, a significant number of patients who develop the Lemierre syndrome received macrolides empirically. Macrolides are never the correct antibiotics for empiric treatment of adolescent/adult pharyngitis.

I hope that this post makes clear my current thoughts. Please ask me for further clarification if I have not answered your questions.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.