A Pain in the Neck
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《新英格兰医药杂志》
To the Editor: In the Clinical Problem-Solving article by Bliss et al. (March 4 issue),1 which involved a case of Lemierre's syndrome, the discussant mentions that the patient's "tonsillar exudates, fever, anterior cervical adenopathy, and absence of cough . . . are highly suggestive of streptococcal pharyngitis" and that "a swab from her pharynx for a rapid streptococcal-antigen test" should be obtained. Recent guidelines and studies have suggested that such patients (those whose condition satisfies all four Centor criteria) can be treated empirically for streptococcal pharyngitis without the need for further testing.2,3 Although the organism usually involved in Lemierre's syndrome, Fusobacterium necrophorum, has shown -lactam resistance in some studies,4 penicillin (the standard treatment for streptococcal pharyngitis) is still thought to have efficacy against the fusobacterium species. Therefore, early use of antibiotics, based on guidelines for the treatment of acute pharyngitis, might have helped to prevent the development of Lemierre's syndrome in this patient.
Craig Nielsen, M.D.
Cleveland Clinic Foundation
Cleveland, OH 44195
References
Bliss SJ, Flanders SA, Saint S. A pain in the neck. N Engl J Med 2004;350:1037-1042.
Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med 2001;134:509-517.
McGinn TG, Deluca J, Ahlawat SK, Mobo BH Jr, Wisnivesky JP. Validation and modification of streptococcal pharyngitis clinical prediction rules. Mayo Clin Proc 2003;78:289-293.
Appelbaum PC, Spangler SK, Jacobs MR. Evaluation of two methods for rapid testing for beta-lactamase production in Bacteroides and Fusobacterium. Eur J Clin Microbiol Infect Dis 1990;9:47-50.
The authors reply: Should the patient in our case discussion have been treated with antibiotics empirically when she first presented with a sore throat? As Dr. Nielsen points out, this approach could have prevented the development of Lemierre's syndrome. Clinicians, however, must balance the desire to prevent suppurative complications with the equally laudable goal of avoiding unnecessary use of antibiotics and increased antibiotic resistance in the community.
Unfortunately, the signs and symptoms of group A streptococcal pharyngitis and viral pharyngitis overlap. Even when all four of the Centor criteria are met, as in our patient, only 56 percent of patients have group A streptococcal infection.1 Although guidelines from the American College of Physicians advocate empirical treatment based on clinical criteria,2 guidelines from the Infectious Diseases Society of America disagree,1 and recent evidence suggests that the former strategy is associated with a high rate of unnecessary antibiotic prescriptions.3 Even though the incidence of Lemierre's syndrome is increasing, it is still very low, approximately one case per million persons.4 Although hindsight in this case perhaps favors empirical antibiotic treatment, we believe that in real time the test-and-treat-if-positive strategy was also a reasonable approach to this patient when she first reported a pain in her neck.
Sandra J. Bliss, M.D.
Scott A. Flanders, M.D.
University of Michigan Health System
Ann Arbor, MI 48109
sbliss@umich.edu
Sanjay Saint, M.D., M.P.H.
Ann Arbor Veterans Affairs Medical Center
Ann Arbor, MI 48105
References
Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis 2002;35:113-125.
Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med 2001;134:506-508. [Full Text]
McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004;291:1587-1595.
Hagelskjaer LH, Prag J, Malczynski J, Kristensen JH. Incidence and clinical epidemiology of necrobacillosis, including Lemierre's syndrome, in Denmark 1990-1995. Eur J Clin Microbiol Infect Dis 1998;17:561-565.
Craig Nielsen, M.D.
Cleveland Clinic Foundation
Cleveland, OH 44195
References
Bliss SJ, Flanders SA, Saint S. A pain in the neck. N Engl J Med 2004;350:1037-1042.
Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med 2001;134:509-517.
McGinn TG, Deluca J, Ahlawat SK, Mobo BH Jr, Wisnivesky JP. Validation and modification of streptococcal pharyngitis clinical prediction rules. Mayo Clin Proc 2003;78:289-293.
Appelbaum PC, Spangler SK, Jacobs MR. Evaluation of two methods for rapid testing for beta-lactamase production in Bacteroides and Fusobacterium. Eur J Clin Microbiol Infect Dis 1990;9:47-50.
The authors reply: Should the patient in our case discussion have been treated with antibiotics empirically when she first presented with a sore throat? As Dr. Nielsen points out, this approach could have prevented the development of Lemierre's syndrome. Clinicians, however, must balance the desire to prevent suppurative complications with the equally laudable goal of avoiding unnecessary use of antibiotics and increased antibiotic resistance in the community.
Unfortunately, the signs and symptoms of group A streptococcal pharyngitis and viral pharyngitis overlap. Even when all four of the Centor criteria are met, as in our patient, only 56 percent of patients have group A streptococcal infection.1 Although guidelines from the American College of Physicians advocate empirical treatment based on clinical criteria,2 guidelines from the Infectious Diseases Society of America disagree,1 and recent evidence suggests that the former strategy is associated with a high rate of unnecessary antibiotic prescriptions.3 Even though the incidence of Lemierre's syndrome is increasing, it is still very low, approximately one case per million persons.4 Although hindsight in this case perhaps favors empirical antibiotic treatment, we believe that in real time the test-and-treat-if-positive strategy was also a reasonable approach to this patient when she first reported a pain in her neck.
Sandra J. Bliss, M.D.
Scott A. Flanders, M.D.
University of Michigan Health System
Ann Arbor, MI 48109
sbliss@umich.edu
Sanjay Saint, M.D., M.P.H.
Ann Arbor Veterans Affairs Medical Center
Ann Arbor, MI 48105
References
Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis 2002;35:113-125.
Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med 2001;134:506-508. [Full Text]
McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004;291:1587-1595.
Hagelskjaer LH, Prag J, Malczynski J, Kristensen JH. Incidence and clinical epidemiology of necrobacillosis, including Lemierre's syndrome, in Denmark 1990-1995. Eur J Clin Microbiol Infect Dis 1998;17:561-565.