Sore Throats More Dangerous than Terrorists

1 in 5 Sore Throats Tied to Scary Bacteria, Study Finds

Thanks, HealthDay.

Now, clickbait headlines aside, what on earth are they referring to?  And, if ~50% of acute pharyngitis already receives inappropriate antibiotics – how can this sort of news release help us maintain any sort of reasonable antibiotic stewardship while also cultivating some modicum of Press Ganey approval?

This is a cross-sectional survey of throat swabs performed on a convenience sample of students at the University of Alabama.  PCR for an expanded cohort of bacterial pathogens was performed on 312 patients presenting to the student health center with acute pharyngitis, and compared with 180 asymptomatic volunteers.  Among symptomatic patients, 20.5% of PCR detected Fusobacterium necrophorum, compared with 9.4% of the asymptomatic cohort, leading to such conclusions as: “approximately 11% of cases of pharyngitis in patients coming to this university health clinic were caused by F. necrophorum.”  Group A Streptococcus, by comparison, was detected in only 10.3% of symptomatic patients and 1.1% of asymptomatic.

So, an epidemic of F. necrophorum?  Should we, as these authors suggest, be considering penicillin for all sore throats – based on the feared complication of Lemierre syndrome – regardless of rapid streptococcal antigen testing?

No.

While, we shouldn’t forget about F. necrophorum, particularly in the adolescent/young adult population, it is important to remember the vast majority of pharyngitis – even bacterial – is self-limited, with minimal benefit from antibiotics, either for symptom relief or suppurative complications.  For Group A Streptococcus, it is reasonable to suggest well over 200 cases must be treated with antibiotics to prevent progressive disease, and rheumatic fever is virtually extinct.  However, we have no similarly useful statistics regarding F. necrophorum – mostly because serious downstream complications are so rare they are still literally one-in-a-million case reports.  Assuming F. necrophorum is as prevalent in the general, or at least young adult, population in which pharyngitis is triaged for antibiotics using solely the rapid strep swab – clearly many swab-negative patients are being discharged with F. necrophorum carriage and no antibiotics, and we simply don’t see pervasive complications.

Symptomatic management and judicious treatment for acute pharyngitis remains the most appropriate strategy, despite the prevalence of this “scary bacteria”.

“The Clinical Presentation of Fusobacterium-Positive and Streptococcal-Positive Pharyngitis in a University Health Clinic”
http://www.ncbi.nlm.nih.gov/pubmed/25686164

8 thoughts on “Sore Throats More Dangerous than Terrorists”

  1. There is some recognition of the microbiome of the pharynx. They don't even recommend swabbing young infants for strep because the colonization incidence far exceeds the pathologic incidence. Does this mean young children can't have symptomatic Group A strep infection? Of course not – but in our modern society, there harms/costs of detection/treatment far exceed the downstream complications (almost nil).

    This is a Centor article, and he's written several pieces for the EM newsletters on the top of Fusobacter. Clearly, it's an entity. I feel rather strongly the microbiome changes go along with the inflammatory changes of pharyngitis, rather than the other way around – because, after all, complicated Fusobacter infection is, while not non-existent, almost vanishingly rare. There is no current reasonable pathway for detection of early, potentially-serious Fusobacter infection with a preventive benefit conferred by antibiotics. So, this remains a curiosity.

  2. Tx. That's what I get for not reading the article linked, sorry. The one "pro-abx" spin I could see on this is that, like pertussis, we'd see more of this entity of abx weren't so widely prescribed. All hail the ubiquitous Zpack!

  3. Tx. That's what I get for not reading the article linked, sorry. The one "pro-abx" spin I could see on this is that, like pertussis, we'd see more of this entity of abx weren't so widely prescribed. All hail the ubiquitous Zpack!

  4. Interestingly, although strep has diminishing susceptibility to azithromycin, fusobacter are. Of course, penicillin is still pretty much always the correct answer.

  5. Is there a NNT and/or NNH for this "scary bacteria" (vs scary anaphylaxis or at least paroxysmal poopy pants syndrome)?

  6. Excellent blog!This is a cross-sectional survey of throat swabs performed on a convenience sample of students at the University of Alabama. PCR for an expanded cohort of bacterial pathogens was performed on 312 patients presenting to the student health center with acute pharyngitis, and compared with 180 asymptomatic volunteers.Articles On Health

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