{"id":5835,"date":"2015-02-21T10:01:06","date_gmt":"2015-02-21T15:01:06","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=5835"},"modified":"2022-02-09T14:09:46","modified_gmt":"2022-02-09T19:09:46","slug":"fusobacterium-pharyngitis-and-the-limits-of-limiting-antibiotics","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/fusobacterium-pharyngitis-and-the-limits-of-limiting-antibiotics\/2015\/02\/21\/","title":{"rendered":"Fusobacterium, Pharyngitis, and the Limits of Limiting Antibiotics"},"content":{"rendered":"

\"\"A paper on pharyngitis in young adults, just published in the <\/a>Annals of Internal Medicine<\/a>,<\/em> is creating a controversy in the intersecting worlds of primary care and Infectious Diseases. The first author is Robert Centor, of the famous Centor criteria<\/a>\u00a0that assess the likelihood of group A strep. He’s been writing about our need to expand diagnostic considerations in sore throat for several years, starting with this excellent editorial.<\/a><\/p>\n

The Physician’s First Watch<\/em><\/a> summary of the new paper was spot-on, so I’ll just quote them here (bolding mine):<\/p>\n

Some 310 young adults (aged 15\u201330) presenting with pharyngitis at an Alabama university clinic underwent polymerase chain reaction testing for bacteria in throat swab specimens; 180 asymptomatic students were also tested. Fusobacterium necrophorum<\/em> was identified in 21% of patients with pharyngitis (and 9% of asymptomatic students), while group A streptococcus was found in just 10% of patients (and 1% of asymptomatic students).<\/strong> Clinical presentations were similar for F. necrophorum<\/em> and group A strep.<\/p>\n

From the perspective of patient management, there are two interpretations circulating about\u00a0this paper\u00a0— one\u00a0that\u00a0it encourages\u00a0antibiotic prescribing, the other that it\u00a0does\u00a0no such thing.<\/p>\n

The controversy is nicely encapsulated in this comment\u00a0on a listerv (remember those?) for pediatricians, which was shared with me from a very reliable source<\/a> (she didn’t write the comment):<\/p>\n

OMG! So if it is cultured [sic] from the throat, it is the cause of the infection,right? So now everyone who has this in their throat and doesn\u2019t feel well needs antibiotics, right?\u00a0<\/span><\/p><\/blockquote>\n

Allow me to take both positions:<\/p>\n

Pro Antibiotics:<\/strong>\u00a0<\/em>Some really terrible exudative pharyngitis in young adults is group A strep negative. This study shows that fusobacterium is more common than strep in this age group. We know it can cause\u00a0peritonsillar abscess and, even worse,\u00a0septic jugular vein thrombophlebitis (Lemierre’s syndrome), both of which are\u00a0preceded by sore throat — and both of which are more common than acute rheumatic fever. If we treat the really sick teenager and young adults who are group A strep negative with an antibiotic with activity against fusobacterium — penicillin and other beta lactams, please, not azithromycin — <\/em>not only will these youngsters get better faster, but we can prevent potentially life threatening complications.<\/p>\n

Versus:<\/p>\n

Anti Antibiotics:<\/strong><\/em> Most pharyngitis is causes by respiratory viruses. There is no way to\u00a0detect fusobacterium as a cause of pharyngitis in clinical practice, so\u00a0if most cases get treated “empirically”, this will be massive unnecessary\u00a0treatment. Detection of the organism by\u00a0polymerase chain reaction in the study does not prove that fusobacterium is the cause of the pharyngitis, especially since it’s found in a not insignificant proportion of asymptomatic individuals (9%). There is furthermore no proof that treatment of fusobacterium will hasten symptom improvement or, more importantly, prevent Lemierre’s.<\/p>\n

The latter position was nicely articulated in an accompanying editorial<\/a> in the Annals<\/em> written by my colleague Jeffrey Linder — a primary care physician who has published extensively on this subject<\/a>\u00a0and admittedly\u00a0a much more reliable expert on the topic than I.<\/p>\n

But let me risk taking a position slightly\u00a0different from Jeff and, I’m sure, many of my ID brethren, one that I confess is rooted not so much in data but in experience caring for several young adults with Lemierre’s. Importantly, Jeff and I don’t disagree — it’s more a matter of emphasis.<\/p>\n

Remember this —\u00a0patients with Lemierre’s are often critically ill. They frequently require ICU care, have high spiking fevers with\u00a0staggeringly high white blood cell counts, and invariably have multiple septic pulmonary emboli with potentially\u00a0other metastatic sites of infection, including the brain.<\/p>\n

It’s a terrifying illness — these are most commonly\u00a0previously healthy high school and college-age kids, so the stakes are high.\u00a0No, we don’t know that treatment of severe pharyngitis “caused” by fusobacterium will prevent Lemierre’s, but doesn’t that\u00a0make biologic sense?<\/p>\n

So let’s go with the pediatricians’ common-sense approach to clinical care, and make a decision about antibiotics based on that sixth sense of “is the kid really sick?” If so, go with some penicillin — especially if at the first encounter they didn’t get treated, and then they come back a few days later even worse.<\/p>\n

Or, if you prefer, listen to the guru of pharyngitis himself, Dr. Centor, and his interpretation of national guidelines<\/a>:<\/p>\n

We believe that following the American College of Physicians\/Centers for Disease Control and Prevention guidelines endorsed by the American Academy of Family Physicians would decrease the risk of Lemierre syndrome in adolescents and young adults. Using these guidelines, physicians can choose to prescribe antibiotics for patients with a pharyngitis score of 3 or 4 (three or four of the following: fever, absence of cough, tender anterior cervical lymph nodes, tonsillar exudate).<\/p>\n

Makes sense to me.<\/p>\n","protected":false},"excerpt":{"rendered":"

A paper on pharyngitis in young adults, just published in the Annals of Internal Medicine, is creating a controversy in the intersecting worlds of primary care and Infectious Diseases. The first author is Robert Centor, of the famous Centor criteria\u00a0that assess the likelihood of group A strep. He’s been writing about our need to expand […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8],"tags":[1020,1026,1032,1035],"class_list":["post-5835","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care","tag-fusobacterium","tag-lemierres-syndrome","tag-penicillin","tag-pharyngitis"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/5835","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=5835"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/5835\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=5835"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=5835"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=5835"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}