Larry K. Kociolek, MD; Stanford T. Shulman, MD
Kociolek L., Shulman S.; Pharyngitis. Ann Intern Med. 2012;157:ITC3-1. doi: 10.7326/0003-4819-157-5-201209040-01003
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Published: Ann Intern Med. 2012;157(5):ITC3-1.
Pharyngitis is discomfort, pain, or scratchiness in the throat due to various infectious and noninfectious causes. Pharyngitis is among the most common reasons for physician visits in adults and children (1). An estimated 15 million outpatient visits were attributed to pharyngitis in 2007 in the United States (2). Sore throat accounts for approximately 1%–2% of all physician office visits (2) and 6% of all visits to pediatricians and family practitioners (3).
Risk factors for pharyngitis vary depending on the underlying cause. Risk factors for noninfectious causes of pharyngitis include smoking (or exposure to second-hand smoke) and a history of allergic rhinitis, the symptoms of which may have seasonal variability. Seasonal variability is also common in many infectious causes, such as respiratory viruses and group A beta-hemolytic streptoccoci (GAS), which are more common in winter and early spring. Because these infections are communicable, close contact with someone who has a sore throat or cold also increases the risk for pharyngitis. Other causes, such as Neisseria gonorrhoeae and HIV, have well-described behavioral risk factors (e.g., sexual activity).
Jan Matthys, Geert Claeys, Marc De Meyere
University of Ghent, Belgium, Department of General Practice, Department of Microbiology
September 27, 2012
Antibiotics in pharyngitis? Only for risk patients and very ill patients.As mentioned by Kociolek et al. (1), clinical scoring systems to stratify patients for their risk for streptococcal pharyngitis are not very useful because physicians substantially overestimate its likelihood.What about laboratory testing? Kociolek et al. recommend the use of streptococcal antigen detection and culture as valid tests for the diagnosis and treatment of streptococcal pharyngitis. After consulting the Internet guidelines on acute sore throat, (2) we cannot share their opinion for the following reasons:There is no international consensus on the use of the rapid antigen detection test (RADT) and throat culture. These tests are not recommended in the guidelines of England, Canada, Scotland, Belgium, and The Netherlands. These guidelines state that the predictive value of the RADT is too low, given the prevalence of streptococcal carriers (5% to 20%) and relatively poor sensitivity of the streptococcal test (70% to 90%); results from a throat culture arrive too late to significantly influence the clinical course and are therefore not used in the aforementioned guidelines. In the European guidelines, as in most developed countries, prevention of acute rheumatic fever and glomerulonephritis are no reasons to prescribe antibiotics. It is strange that in the article of Kociolek this is still a reason to treat pharyngitis.In most European guidelines, acute sore throat is considered a self-limiting disease, and antibiotics are not commonly recommended. This is in accordance with European randomized clinical trials and the Cochrane review. (3) Antibiotics (penicillin) provide only moderate clinical benefits in a minority of patients with pharyngitis, mostly a self-limiting disease with low complication rates. Antibiotics are reserved for severe cases and patients at risk (5% or less), and the current tests are no option in acute pharyngitis.We’d like to remember that penicillin anaphylaxis occurs in approximately 0.015% of patients, with a fatality rate from shock of 0.002% among treated patients (4) and that antimicrobial resistance has emerged as a major public-health crisis. (5) If we continue to prescribe antibiotics for self-limiting illnesses where there is small benefit at most, we will face more and more serious infections like pneumonia and meningitis with resistant bacteria, and an increased associated mortality. We plead for a more judicious use of antimicrobials and not ‘the prompt diagnosis of streptococcal pharyngitis and completion of antibiotic therapy’ as proposed by Kociolek.
1. Kociolek LK, Shulman ST. Pharyngitis. Ann Intern Med. 2012;157:ITC3-1.
2. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. 2007;5:436-43. Review.
3. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD000023.
4. Idsoe O et al (1968) Nature and extent of penicillin side-reactions, with particular reference to fatalities from anaphylactic shock. Bull World Health Organ 38(2):159–188.
5. Furuya EY, Lowy FD. Antimicrobial-resistant bacteria in the community setting. Nat Rev Microbiol. 2006;4:36-45.email: firstname.lastname@example.org
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