Correspondence
Acute Pharyngitis
N Engl J Med 2001; 344:1479-1480May 10, 2001
- Article
To the Editor:
In his review of the diagnosis and treatment of acute pharyngitis in primary care (Jan. 18 issue),1 Bisno assigns surprisingly little importance to the assessment and management of the substantial pain associated with this condition. Patients with pharyngitis come to physicians primarily for relief of the pain that affects them with every swallow. Since acute pharyngitis is generally a benign condition, many clinicians largely ignore the patient's main reason for seeking treatment, even though the pain may be intense enough to override the primordial instinct to drink.
Bisno recommends menthol lozenges and mild local anesthetics for “severe throat pain.” Although mild pharyngitis can often be managed well with lozenges, mild local anesthetics, acetaminophen, or nonsteroidal antiinflammatory agents, moderate-to-severe cases warrant treatment with narcotic analgesics. In addition, a single dose of intramuscular corticosteroids provides stronger and more rapid relief of pain due to pharyngitis with no demonstrated difference in complications.2,3
Bisno appropriately cautions physicians against the indiscriminate use of antibiotics for what is often a viral syndrome, and he recommends delaying antibiotic therapy pending the results of a culture. However, antibiotic therapy has been proved to decrease the duration of pain, albeit modestly, in streptococcal pharyngitis4 — a benefit that must be considered in making decisions about whether to initiate empirical therapy.
4 ReferencesMark J. Sagarin, M.D.
Mount Auburn Hospital, Cambridge, MA 02139James Roberts, M.D.
Mercy Hospital of Philadelphia, Philadelphia, PA 191431
Bisno AL . Acute pharyngitis. N Engl J Med 2001;344:205-211
Full Text | Web of Science | Medline2
O'Brien JF ,Meade JL ,Falk JL . Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med 1993;22:212-215
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Marvez-Valls EG ,Ernst AA ,Gray J ,Johnson WD . The role of betamethasone in the treatment of acute exudative pharyngitis. Acad Emerg Med 1998;5:567-572
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Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Cochrane Review). In: The Cochrane Library. Issue 4. Oxford, England: Update Software, 2000.
To the Editor:
Bisno suggests that “unless streptococcal infection can be ruled out with confidence,” all patients with acute pharyngitis should be tested for group A streptococci by either culture or a rapid test. Although he notes that national advisory committees recommend that negative results on rapid tests be confirmed by culture, he acknowledges that this recommendation may not always be justified “in areas where the incidence of rheumatic fever is quite low.”
Bisno does not specify, however, what level of incidence of rheumatic fever should be considered “quite low,” nor how primary care clinicians are to estimate the risk of rheumatic fever in their geographic area. In most of the United States, unless the patient has features distinctly suggestive of streptococcal pharyngitis, the probability of group A streptococcal infection after a negative rapid test is sufficiently low that culture is probably not necessary.1 In patients with clinical features that are highly suggestive of streptococcal pharyngitis, the probability of disease may be high enough that it would be reasonable to prescribe treatment even if a diagnostic test was negative.2 In such patients, initiating treatment without testing makes sense.
2 ReferencesPaul D. Varosy, M.D.
Thomas B. Newman, M.D., M.P.H.
University of California, San Francisco, San Francisco, CA 941431
Webb KH . Does culture confirmation of high-sensitivity rapid streptococcal tests make sense? A medical decision analysis. Pediatrics 1998;101:E2-E2
CrossRef | Web of Science | Medline2
McIsaac WJ ,White D ,Tannenbaum D ,Low DE . A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998;158:75-83
Web of Science | Medline
To the Editor:
Bisno's review article focuses on the treatment of streptococcal sore throat to prevent rheumatic fever, while deploring the use of antibiotics for 70 percent or more of sore throats among children and young adults in the United States. Rheumatic fever is a disease of socioeconomic conditions as much as of bacteriology. It is rare among well-nourished people living in adequate housing. For example, in Hong Kong as recently as the mid-1970s, rheumatic fever accounted for about 1 percent of admissions to pediatric wards.1 In 2000, I conducted a survey of all 13 hospitals with acute care pediatric wards in this city of 7 million, in which I asked the pediatric cardiology staff how many children with rheumatic fever they could recall having seen within the past five years. They remembered a total of 10, half of whom came from mainland China. Antibiotic treatment for sore throat should depend on local epidemiologic factors. In communities where rheumatic fever is so rare, the approach Bisno describes is irrelevant.
Most patients go to doctors for a “cure” — symptomatic relief of the self-limiting pharyngitis syndromes. Antibiotics have some value for alleviating symptoms, but their effect is partial and slow.2 Aspirin, acetaminophen, and antiinflammatory agents such as ibuprofen, given regularly in adequate doses, relieve pain effectively and quickly.3 As long as some doctors continue the absurd ritual of throat swabs and withhold treatment until a result is available instead of treating symptoms seriously, patients will continue to demand unnecessary antibiotics, and many doctors will provide them.
3 ReferencesJames A. Dickinson, Ph.D., F.R.A.C.G.P.
Chinese University of Hong Kong, Hong Kong, China1
Woo KS ,Kong SM ,Wai KH . The changing prevalence and pattern of acute rheumatic fever and rheumatic heart disease in Hong Kong -- (1968-1978). Aust N Z J Med 1983;13:151-156
CrossRef | Medline2
Whitfield MJ ,Hughes AO . Penicillin in sore throat. Practitioner 1981;225:234-239
Medline3
Thomas M ,Del Mar C ,Glasziou P . How effective are treatments other than antibiotics for acute sore throat? Br J Gen Pract 2000;50:817-820
Web of Science | Medline
Author/Editor Response
Dr. Bisno replies:
To the Editor: I appreciate the correspondents' calling attention to my omission of mention of the usefulness of analgesics in the management of the pain of acute pharyngitis in primary care. The mention of antipyretics was intended to include agents such as acetaminophen and nonsteroidal agents, but it should have been more specific. It is an extremely rare patient with this self-limited illness, however, who would require corticosteroids. One exception may be certain complicated cases of infectious mononucleosis, as pointed out in my review. Drs. Sagarin and Roberts assert that there is “no demonstrated difference in complications” in patients treated with steroids. This may be true, but the two studies they cite included a total of only 72 patients who were so treated, of whom 13 were followed for only 24 hours.
Space limitations did not permit a review of the epidemiology of rheumatic fever, which has been the subject of several of my previous publications. Rheumatic fever is indeed a disease of socioeconomic conditions. In most areas of the United States, rheumatic fever now occurs at a frequency of less than 1 case per 100,000 population for persons whose physicians are in private practice. The risk is higher, however, among disadvantaged children in inner cities. Moreover, the presence of rheumatogenic streptococci can lead to epidemics even in middle-class populations, as evidenced by the occurrence of more than 550 cases in Salt Lake City and environs over the past 15 years. Reasons for treating “strep throat,” even in areas where the prevalence of rheumatic fever is low, are stated in the review.
I am not surprised that my insistence on microbiologic confirmation of suspected streptococcal pharyngitis provoked controversy. Numerous studies over the years have, however, established that even experienced clinicians may err badly in their clinical diagnosis of streptococcal pharyngitis.1 The situation is particularly problematic in adults, in whom the prevalence of pharyngitis due to group A streptococcus may be as low as 5 to 10 percent. Even the most widely cited algorithm2 has a positive predictive value of only 30 to 56 percent. Thus, even with this well-designed and validated algorithm, at least half the prescriptions for antibiotics written by primary care physicians will be for patients without streptococcal infection. Such overtreatment can be obviated by the use of a rapid test. Algorithms are effective, however, in identifying low-risk patients in whom a culture is not required. Microbiologic confirmation of suspected streptococcal pharyngitis is strongly recommended by the American Heart Association,3 the Infectious Diseases Society of America,4 and the American Academy of Pediatrics.5
5 ReferencesAlan A. Bisno, M.D.
Miami Veterans Affairs Medical Center, Miami, FL 331251
Poses RM ,Cebul RD ,Collins M ,Fager SS . The accuracy of experienced physicians' probability estimates for patients with sore throats: implications for decision making. JAMA 1985;254:925-929
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Centor RM ,Witherspoon JM ,Dalton HP ,Brody CE ,Link K . The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1:239-246
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Dajani A ,Taubert K ,Ferrieri P ,Peter G ,Shulman S . Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals. Pediatrics 1995;96:758-764
Web of Science | Medline4
Bisno AL ,Gerber MA ,Gwaltney JM Jr ,Kaplan EL ,Schwartz RH . Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Clin Infect Dis 1997;25:574-583
CrossRef | Web of Science | Medline5
Group A streptococcal infections. In: Pickering LK, ed. 2000 Red book: report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 2000:526-36.
