21/M w/ 2 days abrupt fever, sore throat. No cough/rhinorrhea, rigors, hoarseness. Exam: b/l tonsil exudates, +tender cervical LAD, no neck swelling. No PMH, allergies. Sexually active w/ female partners, no prior STI. 4th gen HIV(-), rapid Strep(-). W/c of the ff is correct?
1/16
Strictly based on guidelines, 31% got the correct answer -- observe/counsel. At some point in our practice, we might have done any of the above choices, which might seem reasonable.
The goal of the Tweetorial is to discuss evidence behind Abx prescription for pharyngitis.
2/16
Respiratory viruses cause the majority of acute pharyngitis (up to 45%). Group A Strep (GAS) is the major bacterial cause & the main indication for Abx. But, it comprises only 10% of acute pharyngitis (higher in other areas).
3/16
Why do we prescribe Abx for GAS? Meta-analysis bit.ly/2PmdXZP
▪️ ⬇️ SSX, transmission
▪️ ⬇️ complication rates: peritonsillar abscess (RR 0.15), otitis media (RR 0.3), acute rheumatic fever (RR 0.27); data for acute GN is inconclusive
4/16
However, the data presented 👆must to take into account:
▪️ Complications are rare. Data from a national database in the UK: # needed to prevent 1 peritonsillar abscess was >4,000! bit.ly/2I4hKHb
▪️ Widespread inappropriate Abx use bit.ly/2PnEzcR
5/16
Therefore, the question one needs to ask is which patient needs to be tested and treated for GAS.
𝓦𝓱𝓸 𝓽𝓸 𝓽𝓮𝓼𝓽?
▪️ Concurrent conjunctivitis, coryza, rhinorrhea, cough strongly suggest a viral etiology 👉 NO testing, Abx; only observe/supportive care
6/16
▪️ Centor criteria (1 point @ fever, no cough, tender cervical lymph node, tonsillar exudates)
👉 0-1: likely viral and not from GAS; NO testing, Abx; only observe/supportive care
👉 ≥2 or ≥3: perform rapid antigen test (RADT) +/- throat Cx bit.ly/2TbRW0D
7/16
RADT (Sn 86%) vs Cx (Sn of 90%). RADT advantage 👉 results available in minutes.
▪️ If RADT (-), Cx indicated only in:
1⃣ high risk of GAS complication (adolescents, immunosuppressed, prior h/o ARF)
2⃣ high GAS prevalence
3⃣ contact w/ high risk for GAS complication
8/16
𝓦𝓱𝓸 𝓽𝓸 𝓽𝓻𝓮𝓪𝓽?
▪️ ACP, CDC bit.ly/2wJE1rf, IDSA bit.ly/32sh8V8 recommend only in symptomatic patients w/ a +RADT/Cx
▪️ W/o +RADT/Cx, empiric Abx is discouraged as SSx of GAS & non-GAS pharyngitis overlap and can lead to inappropriate Abx use
9/16
10 day course of PCN or amoxicillin is recommended for GAS pharyngitis. Alternatives: cephalosporins, clindamycin, macrolides. Caution with macrolide use as rates of GAS resistance is increased in some areas.
10/16
In the approach to a patient with acute pharyngitis, it is 𝓲𝓶𝓹𝓸𝓻𝓽𝓪𝓷𝓽 to have illness scripts for other causes 👇
11/16
Acute HIV, fever/pharyngitis (much like mononucleosis), are very common 👇bit.ly/32yGOiZ
▪️ Warrants high index of suspicion. Opportunity for timely HIV dx. Remember that undiagnosed HIV contributes around 1/3 of HIV transmission 👇 bit.ly/2VhjtQW
12/16
In recent studies, Fusobacterium has emerged as a concerning cause of acute pharyngitis. As we know, it is the leading cause of the dreaded Lemierre Sx (covered here before bit.ly/2Vix8ax 👇) #spacedlearning #retrievalpractice
13/16
In this study by the legendary Dr. Centor @medrants bit.ly/2Vjc2IZ as much as 21% of adults w/ pharyngitis had Fusobacterium (compared to 10% from GAS). This opened up a debate on whether one needs to routinely test and treat for Fusobacterium pharyngitis.
14/16
Fusobacterium, not routinely tested (unless you specifically ask Micro). Also, no rapid/readily available test & no study that empiric coverage prevents Lemierre.
Pls check out @PaulSaxMD beautiful discussion on this topic way back in 2015 👉 bit.ly/3c5PXnm!!
15/16
I also HIGHLY recommend listening to bit.ly/2Pn866h, an Annals On Call podcast on this debate featuring the leading experts on acute pharyngitis: Dr. Centor @medrants & Dr. Linder @jeffreylinder.
16/16
In summary:
▪️ Centor criteria can help select who to test (RADT/Cx)
▪️ Abx only for symptomatic patients w/ +RADT/Cx
▪️ Expand illness script for pharyngitis
ALWAYS observe for response & counsel for warning signs (neck swelling, chills, drooling, stridor, dyspnea, etc).
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