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Pharyngitis -- New Thoughts on When and How to Treat

What is the optimal strategy for treating this common ailment?

"Strep throat" remains a leading cause for physician visits, and researchers have long struggled to determine how best to treat it. Two studies now provide further perspective on various management approaches.

McIsaac and colleagues, in an industry-funded investigation, prospectively assessed six management strategies for children and adults with acute pharyngitis. They compared three strategies based on guidelines from the Infectious Diseases Society of America and the American College of Physicians-American Society of Internal Medicine/American Academy of Family Physicians/CDC with three other approaches (throat cultures for all patients and treatment for those with positive cultures; throat cultures for a subset of patients determined by a clinical prediction tool -- the modified Centor score -- and treatment for those with positive cultures; rapid antigen tests for all patients and treatment for those with positive results). From September 1999 through August 2002, 787 patients with acute sore throat and Centor scores 2 were enrolled; 228 had positive throat cultures, and 194 had positive rapid-test results. In children, the highest sensitivity (100%) and specificity (99%) for streptococcal pharyngitis were achieved with strategies incorporating throat cultures for all or for those with negative rapid-test results. In adults, performing throat cultures for all or for selected patients based on Centor scores had the highest sensitivity (100%) and specificity (96.5%). Treating adults solely on the basis of Centor scores 3 would have resulted in 61% receiving antibiotics -- and 44% receiving them unnecessarily.

Because of an increasing incidence of group A streptococcal pharyngitis that cannot be cured by penicillin, Casey and Pichichero undertook a meta-analysis of studies in which cephalosporins were compared with penicillin for treating pharyngitis in children (35 trials; 7125 patients total). Cephalosporins were significantly better than penicillin in overall rates of both bacterial eradication (odds ratio, 3.02; 95% confidence interval, 2.49-3.67) and clinical cure (OR, 2.34; 95% CI, 1.84-2.97). Subgroup analyses, performed to compensate for limitations in individual trials, also significantly favored cephalosporins over penicillin for both bacterial eradication (7 subgroups) and clinical cure (6 of 7 subgroups).

Comment: Practical factors (e.g., advantages of same-day treatment, effect of testing strategies on staff time, need for telephone follow-up) should be considered in managing pharyngitis, but providing optimal treatment without unnecessary antibiotic prescribing requires the use of strategies with the highest sensitivity and specificity. Although Casey and Pichichero showed cephalosporins to be statistically superior to penicillin, their findings (as noted by editorialists) are limited by the poor quality of the studies involved. In particular, many of these studies might have included chronic pharyngeal streptococcal carriers with concurrent viral illness. Because cephalosporins eradicate streptococcal carriage more effectively than does penicillin, including carriers can artificially enhance cephalosporins' apparent efficacy.

— Richard T. Ellison III, MD

Published in Journal Watch Infectious Diseases May 7, 2004

Citation(s):

McIsaac WJ et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004 Apr 7; 291:1587-95.

• Original article (Subscription may be required)
• Medline abstract (Free)

Casey JR and Pichichero ME. Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics 2004 Apr; 113:866-82.

• Original article (Subscription may be required)
• Medline abstract (Free)

Shulman ST and Gerber MA. So what's wrong with penicillin for strep throat? Pediatrics 2004 Jun; 113. (http://pediatrics.aappublications.org/cgi/data/113/4/866/DC1/1)