ID Pharyngitis =========== þ Fusobacterium - F necrophorum is a gram-negative anaerobe that may cause as much as 10% of pharyngitis cases in adolescents and young adults. It is only rarely implicated in pharyngitis occurring before adolescence. By the target age group, F necrophorum and group A strep both cause about 14% of upper airway infections requiring hospitalization. F necrophorum causes the Lemierre syndrome, a unique suppurative complication that becomes manifest several days after the onset of pharyngitis/tonsillitis. This is a life-threatening constellation of rigors, bacteremia, thrombophlebitis of the internal jugular, and metastatic infection, including pulmonary abscesses. Best estimates are that approximately 1 in 400 cases of F necrophorum pharyngitis will result in the Lemierre syndrome, greatly exceeding the risk, morbidity, and mortality of acute rheumatic fever following strep infection. In a mathematical model, the author suggests that 11 patients will die of F necrophorum complications for every 1 patient who dies from complications of acute rheumatic fever. In their early stages, pharyngitis due to either bacteria are clinically indistinguishable, and the current management paradigm advocates a rapid test for strep and avoidance of antibiotics if the test is negative unless compelling clinical findings exist. If acute pharyngitis does not resolve within 3 to 5 days, if symptoms worsen, or if unilateral neck swelling is noted, clinicians should expand their differential diagnosis to include Lemierre syndrome (as well as peritonsillar abscess, HIV, mononucleosis, and less common strep subtypes.F necrophorum is resistant to macrolides, and treatment regimens should include penicillins, cephalosporins, clindamycin, or metronidazole. Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Annals of internal medicine 2009;151:812-5. þ McIssac Score - the physician assigns one point for each of the following: history of or measured temperature greater than or equal to 38°C, absence of cough, tender anterior cervical adenopathy, tonsillar swelling or exudate, and age less than 15 years. One point is subtracted if the person is 45 years of age or older. If the total score is 1 or less, antibiotic therapy and culture of throat swab are not recommended. If the total score is 2 or 3, culture of a throat swab is recommended, and a decision about antibiotics should be based on the culture results. Patients with a score of 4 or more have the highest likelihood of disease, and either initiating treatment with an antibiotic or taking a throat swab for culture is appropriate. - McIsaac, W. J., V. Goel, et al. (2000). "The validity of a sore throat score in family practice." Cmaj 163(7): 811-5. BACKGROUND: Reducing the number of antibiotic prescriptions given for common respiratory infections has been recommended as a way to limit bacterial resistance. This study assessed the validity of a previously published clinical score for the management of infections of the upper respiratory tract accompanied by sore throat. The study also examined the potential impact of this clinical score on the prescribing of antibiotics in community-based family practice. METHODS: A total of 97 family physicians in 49 Ontario communities assessed 621 children and adults with a new infection of the upper respiratory tract accompanied by sore throat and recorded their prescribing decisions. A throat swab was obtained for culture. The sensitivity and specificity of the score approach in this population were compared with previously published results for patients seen at an academic family medicine centre. In addition, physicians' prescribing practices and their recommendations for obtaining throat swabs were compared with score-based recommendations. RESULTS: Of the 621 cases of new upper respiratory tract infection and sore throat, information about prescriptions given was available for only 619; physicians prescribed antibiotics in 173 (27.9%) of these cases. Of the 173 prescriptions, 109 (63.0%) were given to patients with culture-negative results for group A Streptococcus. Using the score to determine management would have reduced prescriptions to culture-negative patients by 63.7% and overall antibiotic prescriptions by 52.3% (both p < 0.01). Culturing of throat samples would have been reduced by 35.8% (p < 0.01). There was no statistically significant difference in the sensitivity or specificity of the score approach between this community-based population (sensitivity 85.0%, specificity 92.1%) and an academic family medicine centre (sensitivity 83.1%, specificity 94.3%). INTERPRETATION: An explicit clinical score approach to the management of patients presenting with an upper respiratory tract infection and sore throat is valid in community-based family practice and could substantially reduce the unnecessary prescribing of antibiotics for these conditions. þ Journal Watch summary: Practice Guideline Comparisons for Strep Pharyngitis Recommendations for the management of group A streptococcus (GAS) pharyngitis vary from throat cultures or in-office rapid-antigen tests (RATs) for all patients with sore throats to empirical treatment based on clinical scoring systems (such as the modified Centor score [see below{dagger}]). Researchers at a Canadian family practice clinic performed throat cultures and RATs on 787 children and adults who had modified Centor scores of 2 or higher. Six management strategies were evaluated: * (1) Obtain cultures on all patients. Treat culture-positive patients. * (2) Perform RAT in all patients. Treat RAT-positive children and obtain cultures in RAT-negative children; treat only RAT-positive adults (no cultures in adults). * (3) Manage children as in strategy #2. Among adults with Centor scores of 2 or 3, perform RATs and treat RAT-positive patients; among adults with Centor scores of 4, treat empirically. * (4) Manage children as in strategy #2. Empirically treat adults with Centor scores of 3 or higher. * (5) Obtain cultures for all patients with Centor scores of 2 or 3, and treat culture-positive patients; empirically treat patients with Centor scores of 4 or higher. * (6) Perform RATs on all patients. Treat only RAT-positive patients (no cultures in any group). The prevalence of positive throat cultures was 29% (34% in children; 22% in adults). Overall, all strategies except #6 had sensitivities higher than 90% for identifying GAS pharyngitis, and specificities were higher than 93% in all strategies except #4. Unnecessary antibiotic use in children ranged from 0.7% in most strategies to 6.4% in strategy #5; unnecessary antibiotic use in adults ranged from 0.6% in most strategies to 44% in strategy #4. Comment: Among adults, strategy #1 is most effective but also most cumbersome. Strategy #5 is probably the most practical and has the optimal combination of sensitivity, specificity, and low rate of unnecessary antibiotic use. Among children, all strategies have high sensitivity and specificity; #5 has the highest rate of unnecessary antibiotic use (but this was still only 6%). As an easily remembered and practical approach, many physicians might choose #5 for both children and adults, although #1, #2, or #3 would be effective for children as well. - Thomas L. Schwenk, MD {dagger}Modified Centor Scoring System involves the following criteria: temperature, >38øC: 1 point; absence of cough: 1 point; swollen, tender anterior cervical nodes: 1 point; tonsillar swelling or exudates: 1 point; age 3-14 years: 1 point; age 15-44 years: 0 points; age >=45 years: -1 point. Published in Journal Watch April 30, 2004 Source McIsaac WJ et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004 Apr 7; 291:1587-95. þ Empiric Treatment of Acute Pharyngitis [Green SM. Acute pharyngitis: The case for empiric antimicrobial therapy. Ann Emerg Med 1995;3(1):404-6.] þ Pertussis þ Peritonsillar Abscess þ Strep Throat þ Pharyngitis Etiology - Clinical findings tell you nothing about whether it is strep or not. - Strep is almost nonexistent in kids under 3, and rare even in older kids. In adults it is more common. [Putto A. Febrile exudative tonsillitis: viral or streptococcal. Pediatrics 1987 80(1)] - Chlamydia and Ureaplasma are the most common (21%, 18%) causes of pharyngitis in adults (strep is 11% and mono 2%) [Komaroff AL. Serologic evidence of chlamydial and mycoplasmal pharyngitis in adults. Science 1983 222:927] - Study of 106 adults: beta strep 23%, Mycoplasma 9%, Chlamydia TWAR 8%, viral 25%, two pathogens 3%, no findings 31% [Annals Int Med 1989] þ Pharyngitis Treatment - An article in American Family Physician, , recommends patients with a greater than 50% liklihood of streptoccal pharyngitis should be treated empirically and does not recommend any testing. A greater than 50% liklihood of strep pharyngitis was defined as a patient who presented with: 1) fever, 2) cervical adenopathy, 3) erythematous pharynx with or without exudate and no cough or coryza. The chance of strep pharyngitis is also >50% if there is a positive history in other household members. Jeff Myers, NREMTP MSI UNECOM myersj@rpi.edu [Perkins A. An approach to diagnosing the acute sore throat. AFP January 1997, 55(1):131-138] - Erythro vs. placebo for pharyngitis: more side effects from erythro but very effective [J ID 1985 ] - PCN if rapid strep +; erythro if PCN allergic or rapid strep -; for refractory cases, clinda or rifampin. þ Steroids for Severe Pharyngitis þ Effect of antibiotics on pain of pharyngitis: - "Studies have indicated that antibiotics do, in fact, hasten the relief of pain in a strep throat. The archaic practice of doing a culture and then waiting for 24 to 48 hours to begin antibiotics because 'the course is similar with or eithout treatment' has been proven to be erroneous." Roberts JE. Symptomatic treatment for acute pharyngitis. Emerg Med News 1996 18(1):6-7.