Expand the Pharyngitis Paradigm for Adolescents and Young Adults.: F1000 Ranking: "Changes Clinical Behavior"

Larry Bush; Maria T Perez 

Disclosures

Faculty of 1000 

Centor RM
Ann Intern Med 2009 Dec 1 151(11):812-5

Commentary from Faculty Members Larry Bush and Maria T. Perez

Changes Clinical Practice: If pharyngitis in adolescents and adults is empirically treated, consider Fusobacterium necrophorum (FN) as well as group A beta-hemolytic streptococci as equally important potential pathogens and avoid macrolide antibiotics, which may be inadequate.

This perspective article is based on the common notion that most antimicrobial therapy for bacterial pharyngitis in adolescents and adults generally presumes group A beta-hemolytic streptococcus (GAS) to be the etiologic agent. However, Fusobacterium necrophorum (FN) equals GAS in disease prevalence and exceeds it in complications. When empirically treating pharyngitis in this age group, penicillins or cephalosporins, and not a macrolide antibiotic, should be selected to assure adequate coverage against both GAS as well as FN.

The overwhelming majority of episodes of acute pharyngitis in adolescents and adults (15 to 30 years of age) results from infections with viral organisms. Nevertheless, an estimated two-thirds of patients presenting with sore throats are prescribed antibiotic therapy, much of which is empirically based. A shift in the paradigm in treating such cases is suggested and outlined, focusing on the generally unrecognized prevalence of FN pharyngeal disease and the potential life-threatening complication named Lemierre's syndrome, which not uncommonly follows local infection with this gram-negative anaerobe. Lemierre's syndrome, comprising suppurative thrombophlebitis of the internal jugular vein, bacteremia and metastatic infection (e.g. pulmonary and hepatic), is almost always preceded by clinically improved pharyngitis several days before its onset. Several studies are cited pointing out the equal frequencies of approximately 10% of GAS and FN being the causative agent of bacterial pharyngitis in this age population. Reminding us that the key reason for treating GAS pharyngitis is an attempt to decrease the incidence of its potential major complication, i.e. acute rheumatic fever (ARF), the author employs statistical data to point out that the risk for Lemierre's syndrome after FN pharyngitis greatly exceeds that for ARF for GAS. As the best answer as to how to diagnose and who to treat for pharyngitis in this age category is not yet unanimous, he recommends that the 30% of individuals who present with at least 3 of the following: fever history, tonsillar exudates, swollen tender anterior cervical adenopathy, or lack of cough be prescribed an antibiotic regimen that would be sufficient to treat both GAS and FN. The overprescribing of macrolide antibiotics for upper respiratory tract infections, including pharyngitis, has resulted in macrolide resistant isolates of GAS. These agents would also be inadequate in treating disease due to FN and thus may potentiate the risk of subsequent Lemierre's syndrome. Penicillins and cephalosporins should remain the drugs of choice for empiric pharyngitis antimicrobial treatment. References that support the recommended change in clinical practice can be found within the review.

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