Several tweets asked me to answer this question. How would I rewrite sore throat guidelines? Obviously I am biased. So this is my opinion and I am sticking to it!
- I would not change anything about pre-adolescents. Group A strep is the most important bacterial infection and using rapid tests with backup cultures makes sense.
- I would change the guidelines for adolescents and young adults. I would treat patients having Centor scores of 3 or 4 with either penicillin or amoxicillin (augmentin would be fine). I would probably treat some 2s if they looked very ill. I would never use macrolides. If the patient is truly penicillin allergic and looked sick then I would use clindamycin.
- I would have a printed sheet for all adolescent/young adults. I will do a mockup of that sheet in the next paragraph.
- Patients over 30 rarely have pharyngitis. I would treat those patients similarly to adolescent/young adults if they looked sick.
Instructions for adolescents and young adults:
Sore throats should improve over 3-5 days with or without antibiotics. If your sore throat worsens, please return for repeat evaluation.
Beware of the following signs of serious infection:
- Rigors – shaking chills
- Drenching night sweats
- Worsening sore throat
- Unilateral neck swelling
- Shortness of breath
If you have any of those signs you will likely need intravenous antibiotics, so you should go to an emergency department as soon as possible.
Commentary
Most Fusobacterium necrophorum do respond to penicillins. They rarely respond to macrolides. If the patient worsens I would either use clindamycin or add metronidazole. If the patient needs IV antibiotics I would choose either piperacillin/tazobactam, penicillin + metronidazole or clindamycin. If you have any suspicion for peritonsillar abscess or Lemierre Syndrome a limited CT of the neck should provide excellent diagnostic information. If you suspect the Lemierre Syndrome, bedside ultrasound of the internal jugular vein should show the clot.
