25 years of adult sore throats Final

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					25 years of adult sore throats
              or
 How I became an eponym

      Robert M. Centor, MD
     Director, Division of GIM
        Assoc Dean, HRMC
    Clinical Presentation - History

   A 23 yo woman presents with a sore throat.
   She has 2 young children - one recently treated
    with penicillin for a sore throat
   She has been sick for 1 day -high fever
   She has difficulty swallowing
   She denies cough or runny nose.
           Physical examination
   Marked tonsillar exudates
   Tender anterior cervical nodes.
   Temperature of 102.
             Clinical Questions
   What is the probability that this woman has
    strep throat?
   What are the potential benefits of treating her
    with antibiotics if she does have strep throat?
   Would you choose to empirically treat this
    patient or do a diagnostic test?
              Roadmap
   Conventional wisdom
   The original study
   Rapid testing
   Group C
   Rediscovering Lemierre’s
   What do physicians do
   What should physicians do
           Conventional wisdom
… group A streptococcal pharyngitis is the only commonly
occurring form of acute pharyngitis for which antibiotic
therapy is definitely indicated. Therefore, for a patient with
acute pharyngitis, the clinical decision that usually needs to
be made is whether the pharyngitis is attributable to group A
streptococci. - Practice Guidelines for the Diagnosis and
Management of Group A Streptococcal Pharyngitis
(IDSA ) 2002
             The original study
   1980 – working in non-acute ER
   Resident question
   Study design – thanks to Harry Dalton
             Analyzing the data
   Hans Carter
   Learning SAS
   What is logistic regression?
                    The results
   1 point each for:
     Tonsillar exudates
     Swollen, tender anterior cervical nodes

     Lack of cough

     Fever history

   As point total increases, the probability of group
    A strep increases
Interpreting the Clinical Prediction
               Rule
                        Probability of group A Strep

               60

               50

               40
 Probability




               30
                                                       5% prevalence
               20                                      20% prevalence

               10

               0
                    0     1     2     3      4
                          Symptom Score
         How I became an eponym
   Roy Poses and Bob Wigton
   JAMA (Mark Ebell)
     Rational Clincial Exam series:
     Does this patient have a strep throat?

     First known mention of “Centor score”

   Common parlance?
                  Rapid testing
   Uses a variety of techniques to identify the
    Group A antigen from a throat swab
   Excellent specificity
   Variable sensitivity
  A Case of Severe Group-C Beta-
hemolytic streptococcal pharyngitis
   A 30 year old white female complaining of sore-
    throat, high fever and neck swelling
   9 day history
     ER visit on 3rd day – negative rapid test
     ER visit day 5 - worsening symptoms – negative
      rapid test
   Severe (10/10) throat pain, high fever, and
    hoarseness
                Case continued
   Physical examination
     Pharyngitis score = 4
     Temp: 101 Heart Rate: 101 Resp: 18 BP: 122/78

   Throat Exam
     Bilateral tonsillar enlargement, prominent exudates,
      non-displaced uvula
     Mild enlargement of anterior cervical nodes
     Diffuse anterior neck edema
     Diffuse moderate tenderness across anterior neck
              Laboratory Data
   Negative rapid test
   Negative monospot test
   CT of neck showed bilateral thickening of tonsil
    region with no definite abscess
             Diagnostic Studies
   Throat culture – negative for Neisseria
    gonorrhea and chlamydia
   Negative rapid flu test
   Negative EBV and CMV titers
   Negative for HIV
   Throat culture group C streptococcus
   The patient made a full recovery with a 7 day
    course of antibiotics
         Importance of this case
   Differential of worsening pharyngitis
     False negative rapid test
     NGA strep (group C > group G)

     Peritonillar abscess

     Lemierre’s syndrome

     Infectious Mononucleosis

     Acute HIV infection

   Reinforcing the clinical importance of group C
               Group C pharyngitis
   Harry Dalton’s wisdom
   Clinical and microbiological evidence for
    endemic pharyngitis among adults due to group
    C streptococci.
       F A Meier, R M Centor, L Graham, Jr, and H P
        Dalton. Arch Intern Med. 1990 April; 150(4): 825–
        829
 Clinical symptoms and signs in
  sore throat patients with large
   colony variant β–haemolytic
streptococci groups C or G versus
             group A
  M. Lindbaek, E. Hoiby, G. Lermark, et. Al. 2005; British
  Journal of General Practice 2005;55:615-619.
                    Results
   306 sore throat patients – 244 adults
   127 GAS, 33 non-GAS, 146 negative throat
    cultures
    Number of Centor criteria by streptococcal groups in
                       306 patients
Clinical Features           GAS             C or G          Culture –          Total
                           127 (%)          33 (%)           146 (%)          306 (%)


Three or more Centor       61 (48)a         15 (45)          47 (33)          123 (41)
criteria
Two or more Centor         107 (85)a        25 (75)          93 (66)          225 (75)
criteria
a P< 0.05 in bivariate analysis of GAS vs group with no bacteria. GAS = group A
streptococci
                 Implications
   Another in a series of articles which document
    that Group C and Group G beta hemolytic
    streptococci cause endemic pharyngitis
   Combined with Zwart, who found that
    antibiotics decrease disease duration for Group
    C, this paper supports finding and treating
    Group C
The epidemiology of peritonsillar
  abscess disease in Northern
            Ireland

  BC Hanna, R McMullan, G Gallagher, S
  Hedderwick 2006; Journal of Infection
  2006;52:247-253.
                  Study design
   Retrospective review
   All peritonsillar abscess at 3 Northern Ireland
    centers – August 2001 – July 2002
   Microbiological analysis
                        Results
   Culture yield from needle aspirates – throat
    swabs not helpful
   Incidence ~ 1/10000 per year
   Strep
       15 group A, 6 group C
   Anerobes
     10 Bacteroides
     3 Fusobacterium
                  Implications
   Reminds us that peritonsillar abscess patients
    have negative throat swabs
   Reminds us of the diverse microbiology of
    peritonsillar abscess
              Case presentation
   18 yo woman admitted with chest and shoulder
    pain, dyspnea and painful neck swelling
   2 week history of sore throat
   PE
     T 38.8 P 88 BP 100/45 RR 24
     Painful neck swelling – left mandible down the
      anterior border of the sternocleidomastoid
               Case continued
   CT – thrombotic process of left internal jugular
    and multiple cavitating infiltrates in both lungs
   Blood cultures grew Fusobacterium necrophorum
   The patient made a full recovery with 6 weeks of
    penicillin
             Lemierre’s syndrome
   Jugular vein suppurative thrombophlebitis is
    also known as Lemierre's syndrome, postanginal
    sepsis, and necrobacillosis.
   The initiating event is most often pharyngitis,
    frequently in association with tonsil or
    peritonsillar involvement.
   Variety of causes – most common
       Fusobacterium necrophorum
        Lemierre’s syndrome 2006
   Described originally in 1900
   Classic picture described by Lemierre in 1936
    (20 patient series)
   This syndrome was “forgotten” until the 1980s
   Apparent increase over the past 5 years
     UK report
     Milwaukee children’s hospital report
Real-time PCR investigation into the
   importance of Fusobacterium
 necrophorum as a cause of acute
  pharyngitis in general practice
  S. Aliyu, R. Marriott, M. Curran, et al. Journal
  of Medical Microbiology. 2004;53:1029-1035
     Fusobacterium necrophorum
   Most common cause of Lemierre’s syndrome
   Also can cause peritonsillar abscess
   Can cause PSTS (persistent sore throat
    syndrome)
                 Investigation
   100 throat swabs from patients presenting to
    GP with sore throat
   100 throat swabs from health adults (no sore
    throat or antibiotics for 2 weeks)
   PCR investigation of Fusobacterium necrophorum
    specific DNA
                     Results
   Ten sore throat patients positive for
    Fusobacterium necrophorum
   Group A – 16 patients; Group C – 3 patients;
    Group G – 2 patients
   All healthy controls negative
   3 positive patients had recurrent pharyngitis
   1 positive patient had PSTS
   Prevalence of Fusobacterium
   necrophorum and other upper
respiratory tract pathogens isolated
         from throat swabs
  A. Batty and M.W. D. Wren. British Journal
  of Biomedical Science. 2005; 62(2): 66-70.
                   Investigation
   258 throat swabs cultured for
     Group A, C and G
     Corynebacterium diphtheriae

     Arcanobacterium hemolyticum

     Fusobacterium necrophorum

   Samples sent to lab by physicians without
    clinical data
                    Results
   Group A - 27
   Group C - 3
   Group G - 5
   Fusobacterium necrophorum - 24
   Fusobacterium necrophorum more common in young
    adults than in children
                    Summary
   2 laboratory studies suggest that Fusobacterium
    necrophorum may cause endemic pharyngitis
   These studies raise an interesting hypothesis, but
    they do not answer definitively the role of
    Fusobacterium necrophorum in pharyngitis
   These studies also do not address the likelihood
    that Fusobacterium necrophorum will progress to
    Lemierre’s, PSTS or peritonsillar abscess
     Evaluation and
Treatment of Pharyngitis
in Primary Care Practice

  Linder, JA, Chan JC, Bates DW. Arch
     Intern Med 2006;166:1374-1379
                    Investigation
   Chart review of 9 primary care clinics
   4599 adult pharyngitis encounters
       2097 episodes met inclusion criteria
   Recorded and analyzed
     Pharyngitis score
     Testing

     Antibiotic prescriptions
 Antibiotic Prescribing, Streptococcal Testing,
           and a Positive Test Result
                                    No. (%)
Test               Antibiotics   No Antibiotics     Total

Any test            747 (45)        924 (55)      1671 (80)

No test             241 (57)        185 (43)       426 (20)




Positive Test       350 (98)         7 (2)         357 (17)

No positive test    638 (37)       1102 (63)      1740 (83)

Totals              988 (47)       1109 (53)      2097 (100)
      Effect of negative rapid test
   1314 patients had a negative rapid strep test
   397 (30%) received antibiotic prescriptions
Centor Criteria, Streptococcal Testing, and
          Antibiotic Prescribing
Centor     Sample,      Streptococcal   Positive    Antibiotic
Criteria   No. (%)           Test        Test      Prescribing
   0        502 (24)      396 (79)       40 (8)     123 (25)

   1        726 (35)      589 (81)      95 (13)     248 (34)

   2        499 (24)      394 (79)      108 (22)    314 (63)

   3        300 (14)      240 (80)      93 (31)     241 (80)

   4         70 (3)        52 (74)      21 (30)      62 (89)

 Total     2097 (100)     1671 (80)     357 (17)    988 (47)
        Centor criteria and decision
                  making
   As score increases:
     Test positivity increases
     Antibiotic prescribing increases
           Dx and Rx strategies
   ACP empirical – treat 3 & 4
   ACP test – test 2 & 3, treat 4
   IDSA – test 2, 3 & 4
   All assume no testing nor treatment for 0 & 1
  Hypothetical Effect of Perfect Adherence to
             Different Strategies
                               Positive   Antibiotic
Strategy           Testing      Test      Prescribing
Actual cohort     1671 (80)    62 (17)     988 (47)

Strategy
  Test All        2097 (100)   448 (21)    448 (21)
  ACP empirical       0          NA        370 (18)
  ACP test         799 (38)    253 (12)    323 (15)
  IDSA             869 (41)    281 (13)    281 (13)
                    Summary
   The physicians in this study rarely followed
    either guideline
   According to either guideline, they clearly over
    prescribed antibiotics in patients with a low
    probability of bacterial pharyngitis (i.e. 0 & 1
    scores)
   The “debate” between guidelines is much less
    important than convincing physicians to not test
    or treat 0 & 1
                   Summary 2
   Physicians often use inappropriate antibiotics
    (only 60% of prescriptions were for penicillin or
    erythromycin)
   Physicians often ignore rapid test results and still
    prescribe antibiotics
      What should physicians do?
   Pick a guideline
   Follow that guideline
   But which guideline should we choose?
        The philosophical problem
   What is our goal? As we read the two
    guidelines, and study the literature we assume
    two conflicting philosophies:
     What strategy will likely provide the best benefit to
      our individual patient?
     What strategy will cause the least potential public
      health impact?
Implications of the IDSA position
… group A streptococcal pharyngitis is the only
 commonly occurring form of acute pharyngitis for
 which antibiotic therapy is definitely indicated.
 Therefore, for a patient with acute pharyngitis,
 the clinical decision that usually needs to be
 made is whether the pharyngitis is attributable to
 group A streptococci. - Practice Guidelines
  for the Diagnosis and Management of
  Group A Streptococcal Pharyngitis (IDSA )
  2002
                What I believe
   Group A is not the only bacterial etiology which
    deserves antibiotic therapy
   The under use of appropriate antibiotics for
    severe (3 & 4) pharyngitis puts patients at risk
     For suppurative complications
     For increased illness time

   We must emphasize that guidelines only apply to
    the initial presentation of acute pharyngitis
               What I believe 2
   Both guidelines are correct – neither treat nor
    test acute pharyngitis with scores of 0 or 1
   Always use targeted antibiotics for acute
    pharyngitis
                 Implications
   Pharyngitis is a seemingly simple acute problem
   However, research continues to add to our
    understanding of this symptom complex and its
    implications
   We must think critically about all patient
    problems, even those seemingly simple
   Acute pharyngitis provides a great opportunity
    for quality improvement

				
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