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Woldan-Gradalska P, Gradalski W, Gunnarsson RK, Sundvall PD, Rystedt K. Is Streptococcus pyogenes a pathogen or passenger in uncomplicated acute sore throat? A systematic review and meta-analysis. Int J Infect Dis 2024; 145:107100. [PMID: 38762046 DOI: 10.1016/j.ijid.2024.107100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/20/2024] Open
Abstract
OBJECTIVES The objective was to estimate the probability that finding a Streptococcus pyogenes (Group A Streptococcus) in a throat swab in a patient with a sore throat reflects the aetiology. We also investigated to what extent this is influenced by age, carrier rates of S. pyogenes and climate zone. METHODS We conducted a comprehensive search of Medline and Scopus up until October 2023 for case-control studies reporting the prevalence of S. pyogenes in patients with a sore throat and healthy controls. We only included studies with separate data for children and adults. We used the positive and negative etiologic predictive values (P-EPV and N-EPV) to estimate the probability of a link between a sore throat and a finding of S. pyogenes. RESULTS We included 15 studies in our meta-analysis. The overall P-EPV for children and adults were 63% (49-74%) and 92% (87-95%), respectively. The P-EPV rose to 83% (64-93%) for children and 94% (90-97%) for adults when only patients with 3-4 Centor criteria were included. The overall N-EPV was 97% (96-98%) for children and 96% (95-97%) for adults. CONCLUSION Detecting S. pyogenes in adult patients with an uncomplicated acute sore throat is useful to rule in S. pyogenes as the likely aetiologic agent. The P-EPV significantly increased for children when those with 3-4 Centor criteria were selected. A negative throat swab is always useful for both children and adults to rule out S. pyogenes as the cause of sore throat.
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Affiliation(s)
- Patrycja Woldan-Gradalska
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden; Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden; Sätila Primary Health Care Centre, Sätila, Sweden.
| | | | - Ronny K Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden; Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden; The Primary Health Care Clinic for Homeless People, Göteborg, Sweden.
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden; Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden.
| | - Karin Rystedt
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden; Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden; Närhälsan Hentorp Primary Health Care Centre, Skövde, Sweden.
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Moragas A, Sarvisé C, Gómez F, Picó-Plana E, Crispi S, Llor C. Duration of severe and moderate symptoms in pharyngitis by cause. Aten Primaria 2024; 56:102994. [PMID: 38875835 PMCID: PMC11225166 DOI: 10.1016/j.aprim.2024.102994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVE This study aimed to assess the cause of acute pharyngitis and determine the duration of severe and moderate symptoms based on the aetiology. DESIGN Prospective observational study. SITE: One urban health care centre. PARTICIPANTS Patients aged 15 or older with acute pharyngitis were included. INTERVENTIONS Bacterial identification was carried out in the microbiology lab using MALDI-TOF in two throat samples. Patients received a symptom diary to return after one week. MAIN MEASUREMENTS Number of days with severe symptoms, scoring 5 or more in any of the symptoms included in the symptom diary, and moderate symptoms, scoring 3 or more. RESULTS Among the 149 patients recruited, beta-haemolytic streptococcus group A (GABHS) was the most common aetiology. Symptoms and signs alone as well as the mean Centor score cannot distinguish between GABHS and other bacterial causes in patients with acute pharyngitis. However, there was a trend indicating that infections caused by Streptococcus dysgalactiae and Streptococcus agalactiae presented more severe symptoms, whereas infections attributed to the Streptococcus anginosus group, Fusobacterium spp., and those where oropharyngeal microbiota was isolated tended to have milder symptoms. S. dysgalactiae infections showed a trend towards longer severe and moderate symptom duration. CONCLUSION GABHS was the most prevalent, but group C streptococcus caused more severe and prolonged symptoms.
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Affiliation(s)
- Ana Moragas
- Department of Medicine and Surgery, Universitat Rovira i Virgili, Tarragona, Spain; University Institute in Primary Care Research Jordi Gol, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Jaume I Health Centre, Catalan Institute of Health, Tarragona, Spain
| | - Carolina Sarvisé
- Microbiology/Clinical Analysis Laboratori Clínic ICS Camp de Tarragona, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Pere Virgili Health Research Institute (IISPV), Tarragona, Spain
| | - Frederic Gómez
- Department of Medicine and Surgery, Universitat Rovira i Virgili, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Microbiology/Clinical Analysis Laboratori Clínic ICS Camp de Tarragona, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Pere Virgili Health Research Institute (IISPV), Tarragona, Spain
| | - Ester Picó-Plana
- Microbiology/Clinical Analysis Laboratori Clínic ICS Camp de Tarragona, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Pere Virgili Health Research Institute (IISPV), Tarragona, Spain
| | - Silvia Crispi
- Jaume I Health Centre, Catalan Institute of Health, Tarragona, Spain
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Via Roma Health Centre, Catalan Institute of Health, Barcelona, Spain; Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark.
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Boia ER, Huț AR, Roi A, Luca RE, Munteanu IR, Roi CI, Riviș M, Boia S, Duse AO, Vulcănescu DD, Horhat FG. Associated Bacterial Coinfections in COVID-19-Positive Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1858. [PMID: 37893576 PMCID: PMC10607966 DOI: 10.3390/medicina59101858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/22/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: The aim of this study was to identify specific rhino- and oropharyngeal microbiological pathogens as well as associated comorbidities that favor SARS-CoV-2 infection and corelate them. Materials and Methods: This prospective clinical study enrolled 61 patients (28 COVID-19-positive and 33 controls) who were tested for other comorbidities and co-existence of associated oral pathogenic microbiota. Results: A total of 247 bacterial isolates were identified in the bacterial cultures in both groups. Viral hepatitis type A was more prevalent in the COVID-19-positive group (p = 0.026), as was the presence of oral candidiasis (p = 0.006). In the control group, a moderate direct relationship was observed between the Beta hemolytic streptococcus group G and dermatitis, and strong direct relationships were observed between the Beta hemolytic streptococcus group G and external otitis, Streptococcus pyogenes and dental alveolitis, and Streptococcus pyogenes and chronic lymphocytic leukemia. In the test group, strong direct relationships were observed between Hemophilus influenzae and pulmonary thromboembolism; Staphylococcus aureus and autoimmune thyroiditis; post-viral immunosuppression, chronic coronary syndrome, and hypernatremia; Beta hemolytic streptococcus group C and rheumatoid polyneuropathy; Beta hemolytic streptococcus group G and hyperkalemia, hypothyroidism, secondary anemia, and splenomegaly; and active oral candidiasis and SARS-CoV-2 viral pneumonia. The following relationships were strong, but inverse: Beta hemolytic streptococcus group G and acute respiratory failure, and active oral candidiasis and SARS-CoV-2 viral bronchopneumonia. Conclusions: Briefly, COVID-19-positive patients have the predisposition to build up associated comorbidities and coinfections, which can be the expression of the immune burden that this virus generates to the host.
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Affiliation(s)
- Eugen Radu Boia
- Department of Ear, Nose and Throat, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania;
| | - Alexandru Romulus Huț
- PhD Researcher, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania;
| | - Alexandra Roi
- Department of Oral Pathology, Faculty of Dental Medicine, Multidisciplinary Center for Research, Evaluation, Diagnosis and Therapies in Oral Medicine, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania;
| | - Ruxandra Elena Luca
- Department of Oral Rehabilitation and Dental Emergencies, Faculty of Dental Medicine, The Interdisciplinary Center for Dental Medical Research, Lasers and Innovative Technologies, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (R.E.L.); (I.R.M.)
| | - Ioana Roxana Munteanu
- Department of Oral Rehabilitation and Dental Emergencies, Faculty of Dental Medicine, The Interdisciplinary Center for Dental Medical Research, Lasers and Innovative Technologies, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (R.E.L.); (I.R.M.)
| | - Ciprian Ioan Roi
- Department of Anesthesiology and Oral Surgery, Faculty of Dental Medicine, Multidisciplinary Center for Research, Evaluation, Diagnosis and Therapies in Oral Medicine, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.I.R.); (M.R.)
| | - Mircea Riviș
- Department of Anesthesiology and Oral Surgery, Faculty of Dental Medicine, Multidisciplinary Center for Research, Evaluation, Diagnosis and Therapies in Oral Medicine, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.I.R.); (M.R.)
| | - Simina Boia
- Department of Periodontology, Faculty of Dental Medicine, Anton Sculean Research Center for Periodontal and Peri-Implant Diseases, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
| | - Adina Octavia Duse
- Department of Physical Medicine, Balneology and Rheumatology, Faculty of Medicine, Center for the Evaluation of Movement, Functionality and Disability, “Victor Babeș” University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania;
| | - Dan Dumitru Vulcănescu
- Department of Microbiology, Faculty of Medicine, Multidiciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), “Victor Babeș” University of Medicine and Pharmacy Timișoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (D.D.V.); (F.G.H.)
| | - Florin George Horhat
- Department of Microbiology, Faculty of Medicine, Multidiciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), “Victor Babeș” University of Medicine and Pharmacy Timișoara, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (D.D.V.); (F.G.H.)
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Gunnarsson RK, Ebell M, Centor R, Little P, Verheij T, Lindbaek M, Sundvall PD. Best management of patients with an acute sore throat is still best management for these patients. Infect Dis (Lond) 2023; 55:521-523. [PMID: 37198950 DOI: 10.1080/23744235.2023.2212054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Affiliation(s)
- Ronny K Gunnarsson
- Department of Public Health and Community Medicine, General Practice/Family Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Research and Development Center, Södra Älvsborg, Region Västra Götaland, Boras, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
- The Primary Health Care Clinic for Homeless People, Närhälsan, Region Västra Götaland, Gothenburg, Sweden
| | - Mark Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Paul Little
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Morten Lindbaek
- Antibiotic Centre for Primary Care and Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Pär-Daniel Sundvall
- Department of Public Health and Community Medicine, General Practice/Family Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Research and Development Center, Södra Älvsborg, Region Västra Götaland, Boras, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
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Andersen C, Greve T, Reinholdt KB, Kjaerulff AMG, Udholm N, Khalid V, Madzak A, Duez C, Münch H, Pauli S, Danstrup CS, Petersen NK, Klug TE. Bacterial findings in patients referred to hospital for the treatment of acute tonsillitis with or without peritonsillar phlegmon. BMC Infect Dis 2023; 23:439. [PMID: 37386401 DOI: 10.1186/s12879-023-08420-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/22/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND The vast majority of patients with acute tonsillitis (AT) are managed in general practice. However, occasionally patients are referred to hospital for specialized management because of aggravated symptoms and/or findings suggestive of peritonsillar involvement. No prospective studies have been conducted aiming to investigate the prevalent and significant microorganisms in this highly selected group of patients. We aimed to describe the microbiological findings of acute tonsillitis with or without peritonsillar phlegmon (PP) in patients referred for hospital treatment and to point out potential pathogens using the following principles to suggest pathogenic significance: (1) higher prevalence in patients compared to healthy controls, (2) higher abundance in patients compared to controls, and (3) higher prevalence at time of infection compared to time of follow up. METHODS Meticulous and comprehensive cultures were performed on tonsillar swabs from 64 patients with AT with (n = 25) or without (n = 39) PP and 55 healthy controls, who were prospectively enrolled at two Danish Ear-Nose-Throat Departments between June 2016 and December 2019. RESULTS Streptococcus pyogenes was significantly more prevalent in patients (27%) compared to controls (4%) (p < 0.001). Higher abundance was found in patients compared to controls for Fusobacterium necrophorum (mean 2.4 vs. 1.4, p = 0.017) and S. pyogenes (mean 3.1 vs. 2.0, p = 0.045) in semi-quantitative cultures. S. pyogenes, Streptococcus dysgalactiae, and Prevotella species were significantly more prevalent at time of infection compared to follow up (p = 0.016, p = 0.016, and p = 0.039, respectively). A number of species were detected significantly less frequently in patients compared to controls and the mean number of species was significantly lower in patients compared to controls (6.5 vs. 8.3, p < 0.001). CONCLUSIONS Disregarding Prevotella spp. because of the prevalence in healthy controls (100%), our findings suggest that S. pyogenes, F. necrophorum, and S. dysgalactiae are significant pathogens in severe AT with or without PP. In addition, infections were associated with reduced diversity (dysbacteriosis). TRIAL REGISTRATION The study is registered in the ClinicalTrials.gov protocol database (# 52,683). The study was approved by the Ethical Committee at Aarhus County (# 1-10-72-71-16) and by the Danish Data Protection Agency (# 1-16-02-65-16).
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Affiliation(s)
- Camilla Andersen
- Department of Clinical Microbiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, DK-8200, Denmark.
| | - Thomas Greve
- Department of Clinical Microbiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, DK-8200, Denmark
| | - Kasper Basse Reinholdt
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Nichlas Udholm
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Vesal Khalid
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Adnan Madzak
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe Duez
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Münch
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Pauli
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Otorhinolaryngology, Head & Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Sander Danstrup
- Department of Otorhinolaryngology, Head & Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Krintel Petersen
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Otorhinolaryngology, Head & Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
- Aarhus University, Aarhus, Denmark
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Gunnarsson RK, Ebell M, Centor R, Little P, Verheij T, Lindbæk M, Sundvall PD. Best management of patients with an acute sore throat – a critical analysis of current evidence and a consensus of experts from different countries and traditions. Infect Dis (Lond) 2023; 55:384-395. [PMID: 36971650 DOI: 10.1080/23744235.2023.2191714] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND There is a very large body of publications discussing the management of patients with an acute sore throat. Advocates for a restrictive antibiotic policy and advocates for a more liberal use of antibiotics emphasise different and valid arguments and to date have not been able to unite in a consensus. Contradicting guidelines based on the same body of knowledge is not logical, may cause confusion and cause unwanted variation in clinical management. METHODS In multiple video meetings and email correspondence from March to November 2022 and finally in a workshop at the annual meeting for the North American Primary Care Group in November 2022, experts from different countries representing different traditions agreed on how the current evidence should be interpreted. RESULTS This critical analysis identifies that the problem can be resolved by introducing a new triage scheme considering both the acute risk for suppurative complications and sepsis as well as the long-term risk of developing rheumatic fever. CONCLUSIONS The new triage scheme may solve the long-standing problem of advocating for a restrictive use of antibiotics while also satisfying concerns that critically ill patients might be missed with severe consequences. We acknowledge that the perspective of this problem is vastly different between high- and low-income countries. Furthermore, we discuss the new trend which allows nurses and pharmacists to independently manage these patients and the increased need for safety netting required for such management.
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Nygren D, Wasserstrom L, Holm K, Torisson G. Associations Between Findings of Fusobacterium necrophorum or β-Hemolytic Streptococci and Complications in Pharyngotonsillitis-A Registry-Based Study in Southern Sweden. Clin Infect Dis 2022; 76:e1428-e1435. [PMID: 36069108 PMCID: PMC9907503 DOI: 10.1093/cid/ciac736] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/23/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Most pharyngotonsillitis guidelines focus on the identification of group A streptococci (GAS), guided by clinical scores determining whom to test with a rapid antigen detection test. Nevertheless, many patients testing negative with this test are evaluated for group C/G streptococci (GCS/GGS) and Fusobacterium necrophorum, yet their importance remains debated. Our primary aim was to evaluate associations between complications and findings of F. necrophorum, GAS, or GCS/GGS in pharyngotonsillitis. METHODS This was a retrospective, registry-based study of pharyngotonsillitis cases tested for F. necrophorum (polymerase chain reaction) and β-hemolytic streptococci (culture) in the Skåne Region, Sweden, in 2013-2020. Patients with prior complications or antibiotics (within 30 days) were excluded. Data were retrieved from registries and electronic charts. Logistic regression analyses were performed with a dichotomous composite outcome of complications as primary outcome, based on International Classification of Diseases, Tenth Revision, codes. Cases with negative results (polymerase chain reaction and culture) were set as reference category. Complications within 30 days were defined as peritonsillar or pharyngeal abscess, otitis, sinusitis, sepsis or septic complications, recurrence of pharyngotonsillitis (after 15-30 days) or hospitalization. RESULTS Of 3700 registered cases, 28% had F. necrophorum, 13% had GCS/GGS, 10% had GAS, and 54% had negative results. The 30-day complication rates were high (20%). F. necrophorum (odds ratio, 1.8; 95% confidence interval, 1.5-2.1) and GAS (1.9; 1.5-2.5) were positively associated with complications, whereas GCS/GGS were negatively associated (0.7; 0.4-0.98). CONCLUSIONS Our results indicate that F. necrophorum is a relevant pathogen in pharyngotonsillitis, whereas the relevance of testing for GCS/GGS is questioned. However, which patient to test and treat for F. necrophorum remains to be defined.
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Affiliation(s)
- David Nygren
- Correspondence: D. Nygren, Division of Infection Medicine, Department of Clinical Sciences, BMC, B14, Sölvegatan 19, 22362 Lund, Sweden ()
| | - Lisa Wasserstrom
- Department of Clinical Microbiology, Infection Control and Prevention, Skåne University Hospital, Lund, Sweden
| | - Karin Holm
- Division of Infection Medicine, Lund University, Lund, Sweden,Department of Infectious Diseases, Skåne University Hospital, Lund/Malmö, Sweden
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Gunnarsson R, Orda U, Elliott B, Heal C, Del Mar C. What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies. BMJ Open 2022; 12:e059069. [PMID: 35487741 PMCID: PMC9058799 DOI: 10.1136/bmjopen-2021-059069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Identifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings. DESIGN We compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare. SETTING AND PARTICIPANTS The nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies. MAIN OUTCOME MEASURES The proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to. RESULTS In a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3-4 Centor scores (or 2-3 FeverPAIN scores or 3-4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%-15% of patients and prescribing antibiotics to only 3.5%-6.6%. CONCLUSIONS Patients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.
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Affiliation(s)
- Ronny Gunnarsson
- School of Public Health and Community Medicine - General Practice/Family Medicine, Göteborgs universitet Institutionen för medicin, Goteborg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Västra Götalandsregionen, Göteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Göteborg, Sweden
- The primary health care clinic for homeless people, Närhälsan, Region Västra Götaland, Göteborg, Sweden
| | - Ulrich Orda
- Mount Isa Hospital, North West Hospital and Health Service, Mount Isa, Queensland, Australia
| | | | - Clare Heal
- School of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Chris Del Mar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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Pallon J, Sundqvist M, Rööst M, Hedin K. Association between bacterial finding, antibiotic treatment and clinical course in patients with pharyngotonsillitis: a registry-based study in primary healthcare in Sweden. BMC Infect Dis 2021; 21:779. [PMID: 34372771 PMCID: PMC8351112 DOI: 10.1186/s12879-021-06511-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/28/2021] [Indexed: 01/04/2023] Open
Abstract
Background The role of non-group A streptococci and Fusobacterium necrophorum in pharyngotonsillitis has been disputed and few prospective studies have evaluated the effect of antibiotic treatment. This study uses registry data to investigate the relation between antibiotic prescription for pharyngotonsillitis in primary healthcare and return visits for pharyngotonsillitis, complications, and tonsillectomy. Methods Retrospective data were extracted from the regional electronic medical record system in Kronoberg County, Sweden, for all patients diagnosed with pharyngotonsillitis between 2012 and 2016. From these data, two cohorts were formed: one based on rapid antigen detection tests (RADT) for group A streptococci (GAS) and one based on routine throat cultures for β-haemolytic streptococci and F. necrophorum. The 90 days following the inclusion visit were assessed for new visits for pharyngotonsillitis, complications, and tonsillectomy, and related to bacterial aetiology and antibiotic prescriptions given at inclusion. Results In the RADT cohort (n = 13,781), antibiotic prescription for patients with a positive RADT for GAS was associated with fewer return visits for pharyngotonsillitis within 30 days compared with no prescription (8.7% vs. 12%; p = 0.02), but not with the complication rate within 30 days (1.5% vs. 1.8%; p = 0.7) or with the tonsillectomy rate within 90 days (0.27% vs. 0.26%; p = 1). In contrast, antibiotic prescription for patients with a negative RADT was associated with more return visits for pharyngotonsillitis within 30 days (9.7% vs. 7.0%; p = 0.01). In the culture cohort (n = 1 370), antibiotic prescription for patients with Streptococcus dysgalactiae ssp. equisimilis was associated with fewer return visits for pharyngotonsillitis within 30 days compared with no prescription (15% vs. 29%; p = 0.03). Conclusions Antibiotic prescription was associated with fewer return visits for pharyngotonsillitis in patients with a positive RADT for GAS but with more return visits in patients with a negative RADT for GAS. There were no differences in purulent complications related to antibiotic prescription. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06511-y.
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Affiliation(s)
- Jon Pallon
- Department of Clinical Sciences in Malmö, Family Medicine, Clinical Research Centre, Lund University, Box 50332, 202 13, Malmö, Sweden. .,Department of Research and Development, Region Kronoberg, Växjö, Sweden.
| | - Martin Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mattias Rööst
- Department of Clinical Sciences in Malmö, Family Medicine, Clinical Research Centre, Lund University, Box 50332, 202 13, Malmö, Sweden.,Department of Research and Development, Region Kronoberg, Växjö, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Clinical Research Centre, Lund University, Box 50332, 202 13, Malmö, Sweden.,Futurum, Region Jönköping County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Malmberg S, Petrén S, Gunnarsson R, Hedin K, Sundvall PD. Acute sore throat and Fusobacterium necrophorum in primary healthcare: a systematic review and meta-analysis. BMJ Open 2021; 11:e042816. [PMID: 34088705 PMCID: PMC8183226 DOI: 10.1136/bmjopen-2020-042816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The main objective of this review was to describe and quantify the association between Fusobacterium necrophorum (FN) and acute sore throat in primary healthcare (PHC). METHODS In this systematic review and meta-analysis, we searched Scopus and PubMed for case-control studies reporting the prevalence of FN in patients attending primary care for an uncomplicated acute sore throat as well as in healthy controls. Only studies published in English were considered. Publications were not included if they were case studies, or if they included patients prescribed antibiotics before the throat swab, patients with a concurrent malignant disease, on immunosuppression, having an HIV infection, or patients having another acute infection in addition to a sore throat. Inclusion criteria and methods were specified in advance and published in PROSPERO. The primary outcome was positive etiologic predictive value (P-EPV), quantifying the probability for an association between acute sore throat and findings of FN in the pharynx. For comparison, our secondary outcome was the corresponding P-EPV for group A Streptococcus (GAS). RESULTS PubMed and Scopus yielded 258 and 232 studies, respectively. Removing duplicates and screening the abstracts resulted in 53 studies subsequently read in full text. For the four studies of medium to high quality included in the meta-analysis, the cumulative P-EPV regarding FN was 64% (95% CI 33% to 83%). GAS, based on data from the same publications and patients, yielded a positive EPV of 93% (95% CI 83% to 99%). CONCLUSIONS The results indicate that FN may play a role in PHC patients with an acute sore throat, but the association is much weaker compared with GAS.
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Affiliation(s)
- Stefan Malmberg
- General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Susanna Petrén
- General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ronny Gunnarsson
- General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden
| | - Katarina Hedin
- Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Futurum Academy for Health and Care, Region Jönköpings County, Jönköping, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Pär-Daniel Sundvall
- General Practice / Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
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