File: C:\NOTEBOOK\ID-PHAR.TXT 3/12/2018, 09:35:42

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1 ID Pharyngitis =========== þ General Thoughts: - Strep used to be a big problem, and now it's not any more. But the medicalindustrial complex has made testing and treating Group A strep into a juggernaut that keeps on going as the need for it quietly disappears. Dave Newman's famous (infamous?) article argues that we shouldn't give antibiotics for strep as they cause more problems than they fix: (Read the comments, too! Note Robert Centor's.) <Strep-DHN.TXT> I find this moderately persuasive. On the other hand, Centor argues persuasively that Fusobacterium necrophorum is more of a problem than strep, and more common in the college-age person than strep. And non-group A strep (usually C and G) also get better with penicillin. He argues that anyone with three or more of the original Centor criteria should be treated regardless of any strep testing. I find him very persuasive, more so than the recent CDC- ACP guidelines which really don't address Newman or Centor's reasoning at all. - Groups A, C and G strep will show up on a routine clinical throat culture (unless it was a poor sample, or it wasn't stored or transported properly I tell people that, just like a tomato plant, sometimes a throat culture won't grow if you have a brown thumb.) However, F necrophorum is an anaerobe and - Based on my review of the literature, I've change my position on treating tonsillitis. Not that we should treat anyone with 3-4 Centors, which I still believe, but which pathogens we should cover for. I used to worry about myocoplasma, ureaplasma, Legionalla and TWAR Chlamydia. Now I worry more about Group C and G strep and Fusobacterium necrophorum. - People say that URI sx with a sore throat almost always means it's viral. But I see plenty of people (and have experienced myself) posterior but not anterior nasal congestion with no real anterior symptoms or rhinorrhea with bacterial tonsillitis. - For Group A strep, people are likely no longer contagious 24 hours after their first dose of antibiotic. I tell people this is probably true for Group C and Group G strep and Fusobacterium necrophorum. [Snellman, L. W., et al. (1993). "Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy." Pediatrics 91(6): ] - The American Heart Association, as endorsed by the American Academy of Pediatrics, says "Comparative clinical trials used penicillin V dosages of 40 mg/kg (not to exceed 750 mg for those weighing <27 kg) per 24 hours, given in 3 equally divided doses. Generally, 250 mg 2 times daily is recommended for most children (Class I, LOE B). Little information is available about comparable penicillin doses in adults. A dose of 500 mg 2 to 3 times daily is recommended for adolescents and adults (Class I, LOE B). All patients should continue to take penicillin regularly for an entire 10-day period, even though they likely will be asymptomatic after the first few days (Class I, LOE A). Penicillin V is preferred to penicillin G because it is more resistant to gastric acid. An oral, time-released formulation of amoxicillin (Moxatag; MiddleBrook Pharmaceuticals, Westlake, Tex) was recently approved by the US Food and Drug Administration for once-daily therapy of GAS pharyngitis in those 12 years of age and older. In comparative clinical trials, once-daily amoxicillin (50 mg/kg, maximum 1000 mg) for 10 days has been shown to be effective for GAS pharyngitis (Class I, LOE B). This somewhat broader-spectrum agent has the advantage of once-daily dosing, which may enhance adherence, and is relatively inexpensive, and amoxicillin suspension is considerably more palatable than penicillin V suspension." [On the other hand, there's more vomiting with amox. --KC] They say "Even when started as long as 9 days after the onset of acute illness, penicillin effectively prevents primary attacks of rheumatic fever." [Gerber, M. A., et al. (2009). "Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Page: 1

2 Interdisciplinary Council on Functional Genomics and Translational Biology, ]and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics." Circulation 119(11): ] - Since adult compliance sort of sucks, I always prescribe PCN TID rather than BID, figuring that they will miss an occasional dose but still get at least two a day. For kids, compliance is usually better, and I prescribe the liquid BID, figuring one dose before and after school works well. þ My algorithm, based on the information here and linked: - If it's unilateral sore throat both by history, especially if there's unilateral redness in the throat or unilateral tender and swollen nodes in the neck, I worry about an infection with Fusobacterium necrophorum, which can lead to a peritonsillar abscess <PTA.TXT> and regardless of the number of Centors, I treat with an antibiotic that covers F necrophorum, such as penicillin or, if PCN-allergic, cefuroxime (e.g., Ceftin). - If others in the house with strep, and a family member gets a sore throat, treat for strep. Don't do a rapid strep; and if someone does one and it's negative, don't believe it, treat for strep anyway. Even if the rapid strep is negative, the culture always comes back positive. - Use Centor criteria rather than modified Centor/McIssac. Why? + Modified Centor/McIsaac is better at predicting strep, but + I am interested not so much in strep, but whether I should prescribe an antibiotic for the patient, and + The original Centor criteria are better at measuring severity and thus need for an antibiotic (see below). + And, the modified Centor/McIsaac criteria ask about "swollen tonsils" and I have no idea how to determine this (unless I just looked at the patient's tonsils yesterday, but even in that case I'm not sure); but for "exudates" I can easily say yes or no. Sometimes people talk about tonsillar hypertrophy. I'm not sure what that means either. Some people have big tonsils, some people have small tonsils, and some people have no tonsils (or so they say, as they've had a tonsillectomy; I tell them that those big tonsils they had are gone, but tonsils are not just those big things they had removed, but also meeting places for certain kinds of white blood cells, and they still tend to congregate in the same place, but the tonsils never grow as big as they used to be. - Age <3: test for strep only if sibling has strep. Treat only if +. (Strep and rheumatic fever both rare in this group.) - Ages 3-100: + Centor 3 or more: treat with antibiotic. - Don't test for strep. Only exception is if parents are "counting coup" (counting strep throats) to get tonsillectomy. - Penicillin or, if penicillin allergic, clindamycin to cover both strep and F necrophorum. If really sick, both Flagyl for F necrophorum and PCN or clinda for strep. - Don't culture. + If Centor 2, check strep (and F necrophorum once test available), treat only if + or if suspicious of bacterial source (no URI sx, bad-looking). If Centor 2 and looks bad, double-treat with PCN or similar-coverage alternate and Zicam. Don't culture. + If only one Centor, call it viral, and don't test at all. Tell them to take Zicam, which I tell patients is an antiviral antibiotic, which it really is. I tell them that the citrus flavor tastes like moldy grapefruit and that the cherry is not too bad. (Except sometimes it's allergic or from GERD, and if you suspect either of those, treat for it) - Give everyone with Centor 3 or more a dose of oral Decadron unless a contraindication. - Special Situation - Mono: + If has posterior nodes, splenomegaly, insidious onset with severe fatigue, LUQ/L flank pain, classic rash or close mono exposure, check a rapid strep Page: 2

3 (strep and mono may coexist) and check a monospot (which usually takes two weeks of illness to turn positive, but sometimes you're lucky). + If rapid strep negative, do not culture. + Treat with a single dose of steroids. + If monospot negative but very high suspicion of mono, give mono intructions, and have follow up with PCP in a week or so for additional testing. + No role for CBC, EBV/CMV titres acutely; expensive and don't affect treatment. + If unsure if bacterial or mono, and 3 or 4 Centors, treat as above with an antibiotic and follow-up with PCP in a week or so. + If failing standard antibiotic therapy, check a monospot. - Special Situation - Lingual Tonsillitis + Sometimes, I see a patient with classic strep throat/tonsillitis symptoms, with fever, swollen anterior cervical adenopathy, and he or she is having very painful swallowing. But on exam of the pharynx, the palatine tonsils and the surrounding area are only slightly if at all red, and certainly no exudate. + Usually but not always this is someone who has had a tonsillectomy in the past. + Sometimes, with a tongue blade and with one of those patients who can open their throats widely and not gag, I can see the top of the lingual tonsils on the back of the tongue, and they are red, swollen and have whitish exudates. + Sometimes, I can't see the lingual tonsils without a mirror (and I don't have a mirror right then) but based on the patient's terrible grimace when swallowing and degree of fever and very tender anterior adenopathy, I assume that the lingual tonsils are red and have exudates and use that in figuring my Centor criteria. + There is almost no literature on lingual tonsillitis. I treat it just like regular ol' tonsillitis. - Special Situation - Unilateral Tonsillitis + Every now and then, I see someone with a unilateral sore throat. Sometimes this is just a big aphthous ulcer (canker sore) and I just cauterize it with silver nitrate which usually gets rid of the pain, or at least reduces it a lot. + On the other hand, sometimes it really is a unilateral tonsillitis: one tonsil is larger and red. Particularly if this redness is up at the top of the tonsillar pillar where the Weber's glands (salivary glands) are, I worry about an infection with Fusobacterium necrophorum. That's because a peritonsillar abscess is now thought to be an infection of the Weber's glands with F necrophorum, not a consequence of strep tonsillitis. + In such cases, I don't strictly follow the Centor criteria. If there's no ulcer, and no runny nose to suggest it's viral, I just treat with penicillin (or if allergic, cefuroxime (Ceftin) or cefdinir) to cover F necrophorum. þ Group B strep - Comes back occasionally on throat culture. - Found in 25% of normal vaginas so normal flora. - Can cause serious infections in neonates, so if someone has a + culture and around a pregnant woman or neonate, good reason to treat even if improving already. - Treat based on symptoms, if still bad probably reasonable to treat. þ Diptheria - grayish brown pseudomembrane, bleeds when you swab it. - one case (maybe) in US in 1998, rare in developed countries - may have soft tissue swelling > "bull neck" appearance - treat with PCN or Zpak and diptheria antitoxin (have to get from CDC directly) - "In rare cases, A. haemolyticum produces a membranous pharyngitis that can be confused with diphtheria. Erythromycin is the preferred drug for treatment." [Bisno, A. L. (2001). "Acute Pharyngitis." New England Journal of Medicine 344(3): ] Page: 3

4 þ CDC Check List for Assessing a Patient with Suspected Diphtheria + Suspect case: Pharyngitis, naso-pharyngitis, tonsillitis, laryngitis, tracheitis (or any combination of these), absent or low-grade fever; Grayish adherent pseudo-membrane present; Membrane bleeds, if manipulated or dislodged + Probable case: Suspect case above + 1 or more of the following: - Stridor - Bull-neck (cervical edema) - Toxic circulatory collapse - Acute renal insufficiency - Sub-mucosal or subcutaneous petechiae - Myocarditis - Death + Questions to ask: - Recently returned (<2 weeks) from travel to area with endemic diphtheria? - Recent contact (<2 weeks) with confirmed diphtheria case or carrier? - Recent contact (<2 weeks) with visitor from area with endemic diphtheria? - Recent contact with dairy or farm animals? Domestic pets? - Immunization status: Up-to- date - any DTaP/DT/Tdap/Td shot within past 10 years? þ Arcanobacterium - "Arcanobacterium hemolyticum is a relatively uncommon cause of acute pharyngitis and tonsillitis but it is notable for closely mimicking streptococcal pharyngitis, including the production of a scarlatiniform rash in many patients." - "In rare cases, A. haemolyticum produces a membranous pharyngitis that can be confused with diphtheria. Erythromycin is the preferred drug for treatment." [Bisno, A. L. (2001). "Acute Pharyngitis." New England Journal of Medicine 344(3): ] þ GC in the throat - "Although colonization of the pharynx with Neisseria gonorrhoeae is usually asymptomatic, clinically apparent pharyngitis sometimes develops, and pharyngeal colonization may be associated with disseminated disease.33 Gonococcal pharyngitis should be suspected, particularly in women and homosexual men who practice fellatio." [Bisno, A. L. (2001). "Acute Pharyngitis." New England Journal of Medicine 344(3): ] þ Group C Strep - "a careful, prospective analysis of signs and symptoms revealed that the manifestations of Group C-associated pharyngitis were intermediate between those of Group A streptococcal and culture-negative pharyngitis." [Bisno, A. L. (1996). "Acute pharyngitis: etiology and diagnosis." Pediatrics 97(6 Pt 2): ] þ Testing for Strep per Annals of EM 2017: - If rapid strep is negative, in kids, don't send a culture. [Ganti, L. and B. L. Ballinger "How Accurate Is Rapid Antigen Testing for Group A Streptococcus in Children With Pharyngitis?" Annals of emergency medicine.] þ Testing for Strep per CDC, referencing the IDSA 2012 Guidelines: - How Should the Diagnosis of GAS Pharyngitis Be Established? + Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present. In children and adolescents, negative RADT tests should be backed up by a throat culture (strong, high). Positive RADTs do not necessitate a back-up culture because they are highly specific Page: 4

5 (strong, high). + Routine use of back-up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances, because of the low incidence of GAS pharyngitis in adults and because the risk of subsequent acute rheumatic fever is generally exceptionally low in adults with acute pharyngitis (strong, moderate). Physicians who wish to ensure they are achieving maximal sensitivity in diagnosis may continue to use conventional throat culture or to back up negative RADTs with a culture. + Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis as they reflect past but not current events; strong, high). - Who Should Undergo Testing for GAS Pharyngitis? + Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers; strong, high). + Diagnostic studies for GAS pharyngitis are not indicated for children <3 years old because acute rheumatic fever is rare in children <3 years old and the incidence of streptococcal pharyngitis and the classic presentation of streptococcal pharyngitis are uncommon in this age group. Selected children <3 years old who have other risk factors, such as an older sibling with GAS infection, may be considered for testing (strong, moderate). + Follow-up posttreatment throat cultures or RADT are not recommended routinely but may be considered in special circumstances (strong, high). + Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended (strong, moderate). þ Fusobacterium Necrophorum <F-Necro.TXT> - See the study below: almost as common as strep even in adults. And Mycoplasma and TWAR Chlamydia are either less common than we thought or decreasing in incidence. Which means covering for F necrophorum in all adolescents and adults with 3-4 Centors. [Hedin, K., et al. (2015). "The aetiology of pharyngotonsillitis in adolescents and adults - Fusobacterium necrophorum is commonly found." Clin Microbiol Infect 21(3): 263 e ] Sore throat is common in primary healthcare. Aetiological studies have focused on the presence of a limited number of pathogens. The aim of the present study was to investigate the presence of a wide range of bacteria and viruses, including Fusobacterium necrophorum, in patients with pharyngotonsillitis and in asymptomatic controls. A prospective case control study was performed in primary healthcare in Kronoberg County, Sweden. Patients (n=220) aged 15 to 45 years with a suspected acute pharyngotonsillitis, and controls (n=128), were included. Nasopharyngeal and throat swabs were analysed for beta-hemolytic streptococci, F. necrophorum, Mycoplasma pneumoniae, and Chlamydophila pneumoniae, and 13 respiratory viruses. Serum samples were analysed for antibodies to Epstein-Barr virus. The patient history and symptoms, including Centor score, were analysed in relation to pathogens. In 155/220 (70.5%) of the patients, as compared to 26/128 (20.3%) of the controls (p <0.001), at least one microorganism was found. Group A streptococci, F. necrophorum, and influenza B virus were the three most common findings, and all significantly more common in patients than in controls (p <0.001, p 0.001, and p 0.002, respectively). Patients with F. necrophorum only (n=14) displayed a lower Centor score than patients with Group A streptococcus only (n=46), but a higher score than patients with influenza B, other viruses, or no potential pathogen (Kruskal-Wallis p <0.001). A pathogen was detected in 70% of the patients, displaying a wide range of pathogens contributing to the aetiology of pharyngotonsillitis. This study supports F. necrophorum as one of the pathogens to be considered in the aetiology of pharyngotonsillitis. - This one suggests that Group C strep and F necrophorum work synergistically to cause bad tonsillitis. Page: 5

6 [Jensen, A., et al. (2007). "Detection of Fusobacterium necrophorum subsp. funduliforme in tonsillitis in young adults by real-time PCR." Clin Microbiol Infect 13(7): ] Throat swabs from 61 patients, aged years, with non-streptococcal tonsillitis (NST) and 92 healthy controls were examined for the presence of Fusobacterium necrophorum DNA using a novel TaqMan-based real-time quantitative PCR assay for F. necrophorum subspecies. The assay was based on the gyrb subunit gene, and detected F. necrophorum DNA in 48% of patients with NST and in 21% of controls (p <0.001). F. necrophorum subsp. funduliforme was the only subspecies found in both patients and controls. The load of F. necrophorum DNA on swabs from patients with NST was significantly higher than that on swabs from controls (p <0.001). Furthermore, patients with recurrent NST had a significantly higher load of F. necrophorum DNA compared to patients with acute NST (p 0.04). In addition, 26 patients with tonsillitis and group C streptococci (GCS) had a significantly higher load of F. necrophorum DNA compared to the NST group (p <0.001). It was concluded that F. necrophorum subsp. funduliforme is present in small numbers as part of the normal human throat flora, and that F. necrophorum in large quantities may cause tonsillitis, especially recurrent tonsillitis. In addition, the study suggests that the concomitant presence of GCS may aggravate F. necrophorum tonsillitis. - In a 2007 article, Robert M. Centor argues persuasively for empiric treatment of all with 3 or 4 Centors, and examines in great detail the logic that leads him to a conclusion different from that of some recent guidelines, and buttresses these arguments with a clarity and knowledge of the issues that far outstrips the reasoning given in the different society guidelines. [Centor, R. M., et al. (2007). "Pharyngitis management: defining the controversy." J Gen Intern Med 22(1): Despite numerous controlled trials, clinical practice guidelines and costeffective analyses, controversy persists regarding the appropriate management strategy for adult pharyngitis. In this perspective, we explore this controversy by comparing two competing clinical guidelines. Although the guidelines appear to make widely diverging recommendations, we show that the controversy centers on only a small proportion of patients: those presenting with severe pharyngitis. We examine recently published data to illustrate that this seemingly simple problem of strep throat remains a philosophical issue: should we give primacy to relieving acute time-limited symptoms, or should we emphasize the potential societal risk of antibiotic resistance? We accept potentially over treating a minority of adult pharyngitis patients with the most severe presentations to reduce suffering in an approximately equal number of patients who will have false negative test results if the test-and-treat strategy were used. þ Strep Carriers <Carrier.TXT> þ Peritonsillar Abscess <PTA.TXT> þ Sending strep cultures? - I've never been a fan of sending strep cultures. With the algorithm below, we get the majority of Strep A, and also treat for other organisms that are as bad or worse. Even before ultrasensitive/specific rapid streps, I wasn't a fan of culturing. And, if you have the new Alere i rapid strep available, the idea of culturing to confirm this is total nonsense. [Cohen, D. M., et al. (2015). "Multicenter Clinical Evaluation of the Novel Alere i Strep A Isothermal Nucleic Acid Amplification Test." J Clin Microbiol 53(7): ] Rapid detection of group A beta-hemolytic streptococcus (GAS) is used routinely to help diagnose and treat pharyngitis. However, available rapid antigen detection tests for GAS have relatively low sensitivity, and backup testing is recommended in children. Newer assays are more sensitive yet require excessive time for practical point-of-care use as well as laboratory Page: 6

7 personnel. The Alere i strep A test is an isothermal nucleic acid amplification test designed to offer highly sensitive results at the point of care within 8 min when performed by nonlaboratory personnel. The performance of the Alere i strep A test was evaluated in a multicenter prospective trial in a Clinical Laboratory Improvement Amendments (CLIA)-waived setting in comparison to bacterial culture in 481 children and adults. Compared to culture, the Aleri i strep A test had 96.0% sensitivity and 94.6% specificity. Discrepant results were adjudicated by PCR and found the Alere i strep A test to have 98.7% sensitivity and 98.5% specificity. Overall, the Alere i strep A test could provide a one-step, rapid, point-of-care testing method for GAS pharyngitis and obviate backup testing on negative results. þ Mononucleosis: <Mono.TXT> þ Age Differences: - Those <3: + Test only if sibling with strep + rare to have strep [Putto A. Febrile exudative tonsillitis: viral or streptococcal. Pediatrics (1)] þ Pharyngitis Scores: McIssac Score, AKA Modified Centor Score, and Original Centor Score: - Centor Score: from 1992, based on evaluation of 286 adults at a single emergency department, the Centor score helps clinicians distinguish GAS from viral pharyngitis, and thereby appropriately prescribe antibiotics to alleviate symptoms and decrease the rates of acute rheumatic fever, suppurative complications, missed school and work days, and disease transmission. [Fine, A. M., et al. (2012). "Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis." Arch Intern Med 172(11): ] - McIsaac/Modified Centor 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. - This differs from the classic Centor critera as follows: + add a point if less than 15 + subtract a point if 45 or more + original Centor criteria had tonsillar exudates but not swelling. + McIsaac added "tonsillar swelling" but, but given the range of sizes of tonsils, I personally find it hard to grade a tonsil as "swollen" or not. + So the McIsaac is really quite different from the original Centor criteria. [Centor, R. M., et al. (1981). "The Diagnosis of Strep Throat in Adults in the Emergency Room." Medical Decision Making 1(3): [McIsaac, W. J., V. Goel, et al. (2000). "The validity of a sore throat score in family practice." Cmaj 163(7): ] 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 Page: 7

8 patients with sore throats to empirical treatment based on clinical scoring systems (such as the modified Centor score). - 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 - 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: 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 <Pertuss.TXT> þ Peritonsillar Abscess <PeriTons.TXT> þ Strep Throat <I-Strep.TXT> 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 (1)] - Mycoplasma causes a fair bit of exudative pharyngitis. [W, G., et al. (1967). "GRoup a streptococci, mycoplasmas, and viruses associated with acute pharyngitis." Jama 202(6): ] Page: 8

9 Methods for identification of bacteria, viruses, and mycoplasmas were used to study pharyngitis in patients from a pediatric practice. Etiologic agents were recovered from 50% of 715 cultures from patients with pharyngitis and from 22% of 206 cultures from asymptomatic household contracts. Pharyngitis was diagnosed most often in children ages 6 through 8 years, and over one half of these illnesses were associated with group A streptococcus infections. Viruses were the most important cause of pharyngitis in infants, and Mycoplasma pneumoniae was associated with pharyngitis in early adolescence. Disease produced by viruses or M pneumoniae could not be distinguished from classical streptococcal pharyngitis. Mycoplasma hominis, which has produced exudative pharyngitis in adult volunteers, was not recovered from persons in this investigation; however, in other studies performed concurrently, M hominis was isolated from 0.5% of subjects including three adults with pharyngitis. [Komaroff, A. L., et al. (1983). "Serologic evidence of chlamydial and mycoplasmal pharyngitis in adults." Science 222(4626): ] In a study of 763 adult patients we found serologic evidence of infection (a fourfold increase in antibodies) with Chlamydia trachomatis in 20.5 percent of the patients and with Mycoplasma pneumoniae in 10.6 percent, but with group A streptococcus (by culture) in only 9.1 percent. Pharyngitis, the most common problem for which patients seek medical care in the United States, may be caused by nonviral, potentially treatable organisms more often than had been suspected. [Esposito, S., et al. (2006). "Acute tonsillopharyngitis associated with atypical bacterial infection in children: natural history and impact of macrolide therapy." Clin Infect Dis 43(2): ] This study evaluated the natural history of acute tonsillopharyngitis associated with atypical bacterial infections, showing that Mycoplasma pneumoniae and Chlamydia pneumoniae organisms are frequently found in children with acute tonsillopharyngitis. The study also demonstrated, for what we believe to be the first time, that, unless adequately treated, acute tonsillopharyngitis associated with infection with M. pneumoniae and C. pneumoniae may have a negative outcome with a high risk of recurrence of respiratory illness. - There are contradictory views that Mycoplasma and TWAR Chlamydia are normal flora and not infective agents: + "Mycoplasma pneumoniae is isolated with varying frequency in studies of pharyngitis, but the relationship of such isolations to symptoms is problematic. McMillan et a1, for example, recovered the organism from 15.8% of school-aged children with pharyngitis and 17.6% of asymptomatic controls. In general, isolates of M pneumoniae are more common in adolescents and adults than in children. Williams et al4 isolated M pneumoniae from 13% of throat cultures obtained from sore patients seen in family practice in rural Missouri. They found patients from whom M pneumoniae was isolated to be older, less ill, have less evidence of pharyngitis and have more prominent symptoms of tracheobronchitis. Although M hominis has produced mild exudative pharyngitis in human volunteers, its role, if any, in naturally occurring human infections has yet to be established. + "Early reports that Chiamydia trachomatis was a common cause of pharyngitis in adults have not been borne out,but the exact role C pneumoniae remains a subject of investigation. Finally, even when careful microbiologic and virologic studies are carried out, no etiologic agent can be established in a substantial proportion of cases of acute pharyngitis." [Bisno, A. L. (1996). "Acute pharyngitis: etiology and diagnosis." Pediatrics 97(6 Pt 2): ] - More recent study confirms that they do cause infection: atypicals (Mycoplasma, TWAR Chlamydia) as common as strep. (Yes, they did serology to confirm that these were infections and not normal flora found on culture.) [Huovinen, P., et al. (1989). "Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms." Ann Intern Med 110(8): ] STUDY OBJECTIVE: To determine the presence and coexistence of viruses and bacterial organisms causing pharyngitis in adults. DESIGN: Open study using Page: 9

10 diagnostic methods, including rapid antigen-detection techniques, to test for the presence of viruses of the respiratory tract, as well as Mycoplasma pneumoniae. Chlamydia trachomatis, the Chlamydia species strain TWAR, and beta-hemolytic streptococci. SETTING: Open health care. PATIENTS: One hundred six consecutive adult patients, 15 to 65 years old, whose chief complaint was sore throat. MAIN RESULTS: Of the 106 patients, beta-hemolytic streptococci were found in only 24 patients (5 patients with group A streptococci, 13 with group C, 5 with group G, and 1 with group F); M. pneumoniae was found in 10 patients, the Chlamydia species strain TWAR in 9 patients, and viruses in 27 patients. Two microbes were simultaneously isolated in 3 patients, and no microbial findings were detected in 33 patients. CONCLUSION: Because 19 patients were infected with the Chlamydia species strain TWAR and M. pneumoniae, and 24 patients were infected with beta-hemolytic streptococci, the diagnostic procedures and therapies for adult patients with pharyngitis need to be reconsidered. The results of our study also confirm earlier suggestions that the Chlamydia species strain TWAR alone is a causative agent for pharyngitis in adults. - If you infect adults with M hominis, they will get pus-balls on their tonsils. Suspect this study would not pass an IRB these days, (used prison "volunteers") but helpful that they did it: [Mufson, M. A., et al. (1965). "Exudative Pharyngitis Following Experimental Mycoplasma Hominis: Type 1 Infection." Jama 192: ] - A lot of non-strep kid tonsillitis is Mycoplasma. [Esposito, S., et al. (2002). "Emerging role of Mycoplasma pneumoniae in children with acute pharyngitis." Eur J Clin Microbiol Infect Dis 21(8): ] In order to define the role, the risk factors, and the clinical and laboratory characteristics of Mycoplasma pneumoniae infection in children with pharyngitis, 184 patients with acute non-streptococcal pharyngitis (102 males; median age, 5.33 years) were studied. Acute Mycoplasma pneumoniae infection was demonstrated in 44 (23.9%) patients. A history of recurrent episodes of pharyngitis (defined as at least 3 acute episodes of pharyngitis in the 6 months preceding enrollment) appeared to be the more useful parameter for differentiating Mycoplasma pneumoniae pharyngitis from nonstreptococcal non- Mycoplasma pneumoniae pharyngitis ( P<0.05 in multivariate analysis). These data, which highlight the emerging role of Mycoplasma pneumoniae in acute pharyngitis, must be taken into account in the diagnosis and treatment of this clinical manifestation in children. - 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 :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] - More recently, TWAR Chlamydia have been found as a major cause of chronic pharyngitis (maybe we need to treat them properly when they're acute so they don't turn chronic?) [Naina, P., et al. (2012). "Chronic pharyngitis: role of atypical organisms: a case control study from South India." Otolaryngol Head Neck Surg 147(5): ] BACKGROUND: Bacteria including Chlamydophila pneumoniae, Mycoplasma pneumoniae, and anaerobic bacteria such as Fusobacterium necrophorum have been implicated as etiological agents of chronic pharyngitis in Western literature. Because there are no data regarding this from India, the authors undertook this study. STUDY DESIGN: Prospective case-control study. SETTING: Tertiary-level medical college and hospital. METHOD: In total, 343 consecutive adults with persistent throat pain and/or irritation (duration >/=3 months) were screened for known causes of pharyngitis by a thorough clinical and endoscopic examination. In 71 patients, the evaluation performed was unable to determine any cause, and these were considered cases. An enzyme-linked immunosorbent assay test to detect IgA and IgG antibodies to C pneumoniae and M pneumoniae was performed on 66 of these cases and 62 controls. The posterior pharyngeal swabs taken from both the cases and Page: 10

11 controls were subjected to aerobic and anaerobic culture. RESULTS: Individuals with chronic pharyngitis had a 3.43 times odds of being seropositive for C pneumoniae as compared with controls (P =.001; odds ratio = 3.43). Aerobic organisms and M pneumoniae did not seem to be significant etiological agents for chronic pharyngitis. On the contrary, isolation of Fusobacterium spp was found to be significantly more in controls as compared with cases. CONCLUSION: This study suggests an association between IgA antibodies to C pneumoniae and chronic pharyngitis. Further studies using more specific tests combined with long-term follow-up are needed to confirm these findings. [Esposito, S., et al. (2002). "Emerging role of Mycoplasma pneumoniae in children with acute pharyngitis." Eur J Clin Microbiol Infect Dis 21(8): ] In order to define the role, the risk factors, and the clinical and laboratory characteristics of Mycoplasma pneumoniae infection in children with pharyngitis, 184 patients with acute non-streptococcal pharyngitis (102 males; median age, 5.33 years) were studied. Acute Mycoplasma pneumoniae infection was demonstrated in 44 (23.9%) patients. A history of recurrent episodes of pharyngitis (defined as at least 3 acute episodes of pharyngitis in the 6 months preceding enrollment) appeared to be the more useful parameter for differentiating Mycoplasma pneumoniae pharyngitis from nonstreptococcal non- Mycoplasma pneumoniae pharyngitis ( P<0.05 in multivariate analysis). These data, which highlight the emerging role of Mycoplasma pneumoniae in acute pharyngitis, must be taken into account in the diagnosis and treatment of this clinical manifestation in children. 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): ] - 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 <PharSter.TXT> 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 (1):6-7. þ TWAR Chlamydia <TWAR.TXT> Page: 11