Update on treatment of worsening pharyngitis

The Buzz: There's a new possibility to consider when evaluating patients with worsening pharyngitis
Citation: Avoiding sore throat morbidity and mortality: when is it not "just a sore throat?" American Family Physician January 1, 2011 Vol 83:1 p26-7 
Summary: Fusobacterium necrophorum (Fn) is a newly recognized bacterial cause of sore throat and can result a potentially very serious complication called Lemierre syndrome, or septic thrombophlebitis of the internal jugular vein resulting in metastatic pulmonary infections. Patients typically complain of a sore throat which initially improves after 4-5 days but then worsens with symptoms including rigors, fever, night sweats. Mortality is up to 5% of those affected. Lemierre syndrome occurs most often in those aged 15-30 years. Unfortunately there is no laboratory method for diagnosing Fn infections.

So what's a doc to do? First of all, the article reminds us of the differential diagnosis of worsening sore throat including non-group A strep, untreated group A strep (often due to a false negative rapid strep test which can miss up to 10% of cases), infectious mononucleosis, acute HIV infection, peritonsillar abscess, and Lemierre syndrome. Second, we should remember to consider antibiotic treatment in patients with 3 or more of the following: fever, absence of cough, tender anterior cervical lymph nodes and tonsillar exudate. Penicillin remains the drug of choice for presumed strep infections. It also has activity against Fn. If we suspect Lemiere syndrome (recurrence of sore throat with new rigors or fever), clindamycin can be used in well-appearing patients though ER referral/hospital admission for IV antibiotics should be considered for ill-appearing patients with high fevers, rigors, or unilateral neck swelling.
Commentary: While the data are still being gathered, it's a good idea to keep this info in mind when treating patients with persistent or worsening symptoms. 
By: Spencer Blackman MD

Updated guidelines on management of CA-MRSA infections

The Buzz: Updated guidelines clarify approach to this growing problem
Citation: Clinical Infectious Diseases 2011:52  http://cid.oxfordjournals.org/content/early/2011/01/04/cid.ciq146.full.pdf
Summary: Community acquired methicillin-resistant S. Aures (CA-MRSA) infections continue to be on the rise and knowing the appropriate treatment and prevention guidelines is crucial. The Infections Disease Society of America released updated guidelines for the management of skin and soft tissue infections due to CA-MRSA which include the following key points:
- The primary treatment for cutaneous abscess is immediate incision and drainage.
- Antibiotic treatment should be also used for any of the following: multiple sites of infection, signs of systemic infection (fever, etc), rapidly growing infection, concomitant cellulitis, extremes of age, immunocompromise, significant comorbidities, difficult area to drain (e.g. face, hand, genitalia), lack of response to I&D alone.
- For cellulitis with purulence, antibiotic coverage should include empiric CA-MRSA coverage (Bactrim DS 1-2 po bid, Doxy 100 bid, Clinda 300-450 tid, linezolid). Duration of treament is 5-10 days and should be individualized.
- For cellulitis without purulence, empiric beta-hemolytitc streptococcus coverage should be used (Bactrim, Keflex 500 qid, Clinda) but CA-MRSA coverage is likely not needed.
-The use of rifampin as a single agent or as adjunct therapy is not indicated 


The management of recurrent infections with CA-MRSA was also addressed and included:
- Education around frequent hand washing and good hygiene practices
- Avoid reusing personal grooming items (disposable razors, e.g.) and wash all towels/clothes/linens that come in contact with open wounds.
- Focus cleaning efforts on high-touch surfaces like doorknobs and counter tops.
- Decolonization protocols may also be employed and include twice daily intranasal mupirocin 2% for 5-14 days, bathing with antibacterial soaps (chlorhexadine) for 5-10 days, and dilute bleach baths (1/4 cup bleach to 1/4 tub or 13 gallons water) for 15 min twice weekly for up to 3 months.
- Decolonization of household contacts can be considered.

By: Spencer Blackman MD