The 14M had culture confirmed GAS pharyngitis 3 weeks ago, was treated with PCN-VK and symptoms resolved. Now, he's in the ED with signs and symptoms of pharyngitis again, including dysphagia, fever, cough, posterior pharyngeal erythema, swollen tonsils, LAD, and petechiae on his hard palate.
Resources used:
I ordered cultures on each of them and then I opened up MDCalc (I have shortcuts saved to all my devices' desktops) to the Modified Centor Score for Strep Pharyngitis. The easy-to-use calculator tells me that I won't treat the 7F unless positive cultures come back, and the 14M will get empirically covered.
But
what antibiotic do I give him? It seems that he failed PCN-VK.
Traditionally, many have reached for azithromycin next but I had just
read a plea by Dr. Ryan Radecki on his blog EM Literature of Note
to stop using macrolides for strep throat based on a study out of Rush
that reported cases of rheumatic fever secondary to macrolide
resistance. The paper also notes as high as a 15% US single center
resistance rates.If not a z-pack, then what? I opened the EMRA Abx guide which recommended cephalexin or clindamycin. I chose cephalexin, rechecked in Micromedix the indications and dosing, and felt confident I had made the right choice. I also noted to myself that if in the future I were treating a child with a history of PCN anaphylaxis, then clindamycin would be my choice.
I went home that night, read the paper and tweeted Ryan. He and Dr. Graham Walker (MD Calc) were already having a conversation about the issue and I asked them what their second line choice of antibiotic is?
Finally, I went on my favorite quick reference resource WikEM. Their entry on strep pharyngitis was recommending azithromycin as the second line drug. I updated the site, and referenced the article.
This post can be found as part of a guest series on Dr. Michelle Lin's blog, Academic Life in Emergency Medicine.
What's missing from the discussion is that Dr. Centor (yes, of Centor Criteria fame) is among those less concerned with GAS pharyngitis these days and more concerned with Fusobacteria necrophorum pharyngitis, which occurs as commonly as strep and with greater morbidity and mortality.
ReplyDeleteSo yes -- this is a pharyngitis as common as strep throat that is actually killing some teenagers!
About 1 in 400 F necrophorum pharyngitis cases progress to a Lemierre syndrome (septic thrombophlebitis of the IJ), with a 2-5% mortality rate. Sure, progression to Lemierre's is rare -- but compare that to the rational for treating strep pharyngitis, which is that ~ 1 in 10,000 progress to rheumatic heart disease.
F necrophorm is susceptible to penicillin but immune to macrolides. Yet another reason to avoid Azithromycin.
Dr. Centor now favors treating adolescents with 3 or more of his criteria.
In fact, we now have the bizarre situation where a *negative* strep test is a more compelling reason to treat with antibiotics than a positive strep test. (Strep pharyngitis has a 99.9999 % chance of resolving untreated without the patient developing rheumatic heart disease. F necrophorum apparently has ~ 95-98% chance of resolving untreated without the patient developing a septic thrombophlebitis of the internal jugular and possibly dying from that. Hmm.)
The natural history of routine pharyngitis is resolution in 3 to 5 days. If it's not resolving or worsening, the differential diagnosis expands, to include acute HIV, mono, or a suppurative complication like an abscess or the Lemierre syndrome.
- Centor RM. "Expand the pharyngitis paradigm for adolescents and young adults." Ann Intern Med 2009 Dec 1; 151:812.
- Centor RM, Geiger P, Waites K. "Fusobacterium necrophorum bacteremic tonsillitis: 2 Cases and a review of the literature." Anaerobe 16 (2010) 626-628.
Brilliant blog, thank you very much. It seems very well written and I have taken my time to read it thoroughly.
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