Sore Throat: Avoid Overcomplicating the Uncomplicated
Authors: Jeffrey A. Linder
Journal: Annals of Internal Medicine (2015)

Letters16 June 2015Sore Throat: Avoid Overcomplicating the UncomplicatedJeffrey A. Linder, MD, MPHJeffrey A. Linder, MD, MPHFrom Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L15-5100-2 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:I agree with Dr. Centor about quite a lot in the management of patients with sore throat. In developed countries, rheumatic fever is a minor concern. Patients with Centor scores of 0 or 1 can be safely reassured. Those diagnosed with bacterial pharyngitis should be treated with penicillin. Physicians should not be overly anchored to guidelines if their patients are not doing well. The Lemierre syndrome can be devastating. However, we have legitimate disagreements. Dr. Centor's arguments recall other examples of injudicious antibiotic use.The use of empirical penicillin to prevent the Lemierre syndrome is reminiscent of the discredited practice of antibiotic prophylaxis for patients with heart murmurs to prevent infective endocarditis. Even if Fusobacterium pharyngitis were clearly linked to the Lemierre syndrome, only a tiny fraction of patients with Fusobacterium pharyngitis will develop the Lemierre syndrome. Dr. Centor has estimated it to be 1 in 400 (1), but the rate could be much, much lower (2). There is no evidence that antibiotics prevent the Lemierre syndrome.Pharyngeal detection of F. necrophorum is reminiscent of the detection and unnecessary treatment of group A streptococcus carriers. Point-of-care testing for group A streptococcus does not differentiate between true infection and carriage. Similarly, a "convoluted explanation" is not required to show that F. necrophorum does not necessarily cause pharyngitis; this organism is a normal part of the oropharyngeal flora (Dr. Centor and colleagues detected F. necrophorum in 9% of asymptomatic young adults). During viral infection, F. necrophorum overgrows and becomes more easily detected. Detection is not infection.Finally, "F. necrophorum fear" is reminiscent of antibiotic prescribing for "bacterial acute bronchitis." There is no evidence that antibiotics substantively alter the course of acute bronchitis, but physicians prescribe these agents to 70% of adults with acute bronchitis (3). Similarly, raising the specter of F. necrophorum encourages antibiotic use at a time when physicians already prescribe antibiotics to approximately 60% of young adults with pharyngitis (4).These areas of disagreement can be addressed with new evidence. Studies can and should examine whether F. necrophorum causes a meaningful proportion of pharyngeal infections and whether antibiotic treatment of F. necrophorum–associated sore throat decreases symptoms and prevents complications.Present evidence points to widespread overprescribing of antibiotics.Jeffrey A. Linder, MD, MPHBrigham and Women's Hospital and Harvard Medical SchoolBoston, MassachusettsReferences1. Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med. 2009;151:812-5. [PMID: 19949147] doi:10.7326/0003-4819-151-11-200912010-00011 LinkGoogle Scholar2. Petersen I, Johnson AM, Islam A, Duckworth G, Livermore DM, Hayward AC. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007;335:982. [PMID: 17947744] CrossrefMedlineGoogle Scholar3. Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996-2010. JAMA. 2014;311:2020-2. [PMID: 24846041] doi:10.1001/jama.2013.286141 CrossrefMedlineGoogle Scholar4. Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997-2010. JAMA Intern Med. 2014;174:138-40. [PMID: 24091806] doi:10.1001/jamainternmed.2013.11673 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2899. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoSore Throat: Avoid Overcomplicating the Uncomplicated Jeffrey A. Linder Sore Throat: Avoid Overcomplicating the Uncomplicated Jeffrey A. Linder Sore Throat: Avoid Overcomplicating the Uncomplicated Robert M. Centor , T. Prescott Atkinson , Carlos Estrada , and Ken B. Waites Sore Throat: Avoid Overcomplicating the Uncomplicated Robert M. Centor , T. Prescott Atkinson , Carlos Estrada , and Ken B. Waites Metrics Cited ByAnalysis of the tonsillar microbiome in young adults with sore throat reveals a high relative abundance of Fusobacterium necrophorum with low diversityThe long shadow of Lemierre’s syndrome 16 June 2015Volume 162, Issue 12Page: 878-879KeywordsAntibioticsBronchitisDisclosurePenicillinPharyngitisRheumatic feverStreptococcal infectionsStreptococcusYoung adults ePublished: 16 June 2015 Issue Published: 16 June 2015 CopyrightCopyright © 2015 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...