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A recent article highlights that Fusobacterium necrophorum is the cause of around 10% of acute pharyngitis cases in adolescents and young adults. One of the supparative complications of this infection is Lemierre’s syndrome, which can be potentially life-threatening. Empirical, immediate antibiotic prescribing (penicillin or cephalosporin, but not a macrolide) is recommended when three or more Centor criteria* are present.
Action
Healthcare professionals in primary care should continue to follow NICE clinical guideline 69 for antibiotic prescribing in respiratory tract infections for adults and children presenting with acute sore throat/pharyngitis/tonsillitis.
For most patients (adults and children) a no antibiotic or delayed antibiotic prescribing strategy is appropriate. Depending on clinical assessment of severity, immediate antibiotic prescribing should be considered for patients when three or more Centor criteria are present. These are:
- presence of tonsillar exudate
- presence of fever
- presence of cervical lymphadenopathy
- absence of cough.
Immediate antibiotic and/or further appropriate investigation and management is appropriate for those likely to be at risk of complications (see NICE guideline for details). Penicillins and cephalosporins (but not macrolides) are suitable first-line antibiotics when empirical prescribing is appropriate.
What is the background to this?
Most sore throats are largely viral in nature and self limiting, and antibiotic treatment is unnecessary. Most patients who consult their GP with acute sore throat are not at major risk of serious complications, and a no antibiotic or delayed antibiotic strategy is appropriate, in accordance with the NICE clinical guideline on the prescribing of antibiotics for self-limiting respiratory tract infections.
The difficulty prescribers face lies in identifying the small number of patients who will suffer severe and prolonged illness, or more rarely, go on to develop complications. The NICE clinical guideline provides a safety net whereby patients who are at risk of developing complications are prescribed antibiotics immediately. Those who are offered a no antibiotic or a delayed antibiotic strategy are advised on managing symptoms, and to use their delayed prescription and/or reconsult as appropriate.
What does the article claim?
This Perspectives article in the Annals of Internal Medicine considers the causative organisms and antibiotic treatments to avoid potential complications in adolescents and young adults who present with sore throats. Most antimicrobial therapy for bacterial pharyngitis has focussed on a group A beta-haemolytic streptococcus (GABHS) as the causative agent and the avoidance of the associated complication of acute rheumatic fever. However, this article, citing several studies, points out that another organism, Fusobacterium necrophorum (FN), a gram-negative anaerobe, occurs at a similar frequency to that of GAS in young adults and adolescents with acute pharaygitis (about 10%). FN can cause suppurative complications including Lemierre’s syndrome, which can be life-threatening. Lemierre’s syndrome is considered to be a more dangerous and probable complication of pharyngitis than rheumatic fever in young adults and adolescents. In the absence of clinical data, and no simple means of identifying FN, the author recommends that the 30% of patients who present with at least three of the Centor Criteria* be prescribed an antibiotic strategy that would be sufficient to treat both GAS and FN. Penicillins and cephalosporins are considered appropriate antibiotics for this; macrolide antibiotics, to which FN is not sensitive, is not recommended.
So what?
The recommendation to prescribe antibiotics immediately for young adults and adolescents with at least three Centor criteria* is consistent with NICE guideline 69, although the guideline only suggests ‘considering’ antibiotics under such circumstances depending on a clinical assessment of severity. As a rapid response to the article indicates, it is not certain that the isolation of FN from a throat swab of a sore throat patient equates to causation. Empirical treatment of all patients with three or more Centor criteria* could lead to considerable unnecessary therapy for viral pharyngitis in young people. No recommendations for which antibiotic to prescribe empirically is given in the NICE guideline, although the recommendation in this article to avoid macrolide antibiotics in young adults and adolescents would seem reasonable, given the frequency of FN in acute pharyngitis and its lack of sensitivity of FN to macrolides.
More information on the management of common respiratory tract infections including sore throat can be found on the respiratory tract section of NPC
*Centor criteria are:
- presence of tonsillar exudate
- presence of fever
- presence of cervical lymphadenopathy
- absence of cough.
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