Adult Sore Throats

Throat, soreThis is the tail end of flu, cold and sore throat season. All my healthy adult patients are busy with business and social events and family visitors. None of us have time to be sick. At the first sign of a sore throat, runny nose and cough I am being asked to prescribe an antibiotic. In most cases adult sore throats are caused by viruses which do not respond to antibiotics. Not only are antibiotics ineffective but their side effects may make you as ill or worse than the illness you are attempting to treat. “I know my body and it always responds to a Z-Pack,” is a common phrase heard in local medical offices, walk in centers and emergency departments.

With this as a background it was interesting to see a publication in the Annals of Internal Medicine this month investigating the causes of a sore throat. Dr. Robert M. Centor, from the Department of Internal Medicine at the University of Alabama in Birmingham, performed throat swabs on 312 patients reporting a sore throat at a university health clinic and compared the results with the throat swabs of 180 healthy but similar students. Dr. Centor has developed a clinical algorithm and scale for determining when one should do a throat culture and when it is likely that the sore throat is due to Group A Streptococcus and requires antibiotics. Dr. Centor had the advantage of using polymerase chain reaction techniques to look for anaerobic mouth bacteria called fusobacterium necrophorum that normally resides in the mouth, can cause infection but is not detectable by routine and commercially available tests.

Dr. Centor found that 10% or less of adult sore throats are caused by bacteria specifically Strep throat. An accompanying editorial on the subject reminded physician readers that good old fashioned penicillin is still the drug of choice for a Strep throat with no resistance ever having been detected. They went on to say that an increasing percentage of Strep throats are resistant to a Z Pack so it should not be the drug of choice.

Dr. Centor in his scoring scale noted that if you didn’t have a cough, swollen or tender cervical lymph glands, a temperature > 100.4 and a tonsillar exudate, you probably didn’t need a throat swab for strep A. In adults, when a rapid Strep test was performed and it was negative there was little if any chance that a traditional throat culture would have a different result.

The message from this is that if you are an adult and have not been around young sick children then your sore throat is probably viral and does not need an antibiotic. If your temperature isn’t elevated and your glands aren’t swollen and your tonsils and throat don’t have a white coating then you probably do not have a bacterial strep sore throat either. Grab those lozenges, sucking candies, warm fluids and wait it out.

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Dr. Reznick is board certified in internal medicine and has practiced in Boca Raton and the surrounding communities since 1979. For information about his concierge practice, call 561.368.0191 or visit http://www.BocaConciergeDoc.com.

Infectious Disease Society of America Updates Guidelines for Strep Throat

The Infectious Disease Society of America updated its 2002 guidelines for the diagnosis and treatment of Group A streptococcal sore throat.  In adults with a sore throat, only 5 – 15% actually have Group A streptococcal sore throat and require an antibiotic to treat the illness. Adults in that group usually have been in the proximity of young children or adolescents who have strep throat.  In 85 – 95% of the cases, the adults have a viral illness that is causing their sore throat and viruses do not respond to the use of antibiotics.    For patients at risk for Group A streptococcal sore throat, usually presenting with fever, swollen neck lymph glands and an exudative pharyngitis; it is recommended that a rapid antigen detection test be performed to confirm the diagnosis and appropriately start the patient on antibiotics.

According to Stanford Shulman, MD of Northwestern University’s Feinberg School of Medicine in Chicago, once the rapid antigen detection test is positive no confirmatory formal throat culture is necessary.  If the test is negative in a child or adolescent only, they recommend performing a formal throat culture to rule out the bacterial infection. This is not necessary for adults because there is a low risk of them having this type of infection and very low risk of complications like rheumatic fever.

Once strep throat is diagnosed, the treatment of choice remains penicillin or amoxicillin taken for 10 full days. If the patient is penicillin allergic, alternative choices of antibiotics including cephalosporins, clindamycin or clarithromycin are warranted.  Acetaminophen and non steroidal anti-inflammatory medications are acceptable to reduce discomfort and symptoms.

Distinguishing between a viral sore throat and bacterial Group A streptococcal sore throat is very difficult using symptoms alone since the bacteria have changed their presentation as an adaptive survival mechanism. Most clinicians however feel confident that if the patient has a runny nose (rhinorrhea), hoarseness, mouth ulcers and cough it is probably viral and does not require antibiotics.

This guideline change comes on the heels of a report in the Archives of Internal Medicine pointing out that antibiotic use by senior citizens in the southern United States is more frequent in January through March than in other parts of the country. The study talks about the inappropriate use of oral antibiotics during the cold and flu season leading to bacteria becoming resistant to simple and inexpensive antibiotics.  In addition to a resistance to antibiotics, we are observing an increased number of complications of antibiotic use such as antibiotic related colitis (clostridium difficile).

This information is presented as an educational effort especially for patients who demand an antibiotic inappropriately when they catch a cold (viral illness) or who demand an antibiotic when they travel “just in case I catch a cold”.

Should We Treat Sore Throats With Antibiotics?

How many of us have called our doctor with a scratchy throat, mildly swollen glands, congestion and overall malaise and requested an antibiotic?   “I know my body best and if I take an antibiotic I knock it out quickly.” is a common refrain.

In most cases, sore throats are due to viruses. Fewer than 10% of sore throats are caused by bacterial Group A streptococcus.  Antibiotics such as a Z-Pack (Zithromax), Penicillin or Ampicillin do not kill viruses.  If by chance a patient has a sore throat and an upper respiratory tract infection, the length of illness before recovery averages 4-7 days with or without antibiotics -whether strep is present or not.

How then did the throat culture and use of antibiotics begin and what is its rational? In the 1940’s and 1950’s when antibiotics were being introduced to the public it was determined that streptococcus pyogenes was the cause of Rheumatic Fever.  Researchers found that by administering antibiotics to patients with a strep throat they could reduce the rate of acute Rheumatic Fever from 2% to 1% (notice that even with appropriate antibiotic use we cannot prevent all the cases of Rheumatic Fever).

Applying this data in 2011 we find that there is about 1 case of Rheumatic Fever in the United States per 1 million cultured strep throats. In other words, we must prescribe one million prescriptions for antibiotics for sore throat to prevent one case of Rheumatic Fever. In turn, these antibiotics may cause 2,400 cases of allergic reactions, 50,000 cases of diarrhea and an estimated 100, 000 skin rashes.  It doesn’t make sense.

In a recent editorial article in MedPage, an online periodical supported by the University Of Pennsylvania School Of Medicine, George Lundberg M.D. presented a cogent case against throat culture use and antibiotics in sore throats and bronchitis. He suggested that “physicians should not prescribe antibiotics for sore throats….  They don’t help. They often hurt. First, do no harm!”

As an internist dealing with adult patients I am not seeing the groups most likely to catch a strep throat which is young children 2-7 years of age and their caregivers.  If patients present with fever, exudative tonsillitis and pharyngitis with large swollen cervical lymph nodes I will still culture them.  I will treat based on their immune status, general health and risk of having a significant bacterial infection. If I choose to prescribe an antibiotic I will make an adjustment based on the culture results.