Robert M Centor MD MACP Immediate Past Chair ACP BOR Regional Dean HRMC UAB Roadmap Clinical reasoning System 1 Intuitive FAST System 2 Analytic SLOW My evolving problem representation and illness scripts ID: 752298
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Slide1
Adolescent & Adult Pharyngitis 2015
Robert M. Centor, MD,
MACP
Immediate Past Chair, ACP BOR
Regional Dean
, HRMC, UABSlide2
RoadmapClinical reasoning
System 1 – Intuitive (FAST)
System 2 – Analytic (SLOW)
My evolving problem representation and illness scripts
Adult sore throats – morbidity & mortality
And why?
Take home lessonsSlide3
GoalsUnderstand dual-process theory of clinical reasoning
Understand
why we should expand the pharyngitis paradigm
Understand red flags in
pharyngitis (changing the illness script)
Understand when to invoke analytic reasoningSlide4
Not
Independent!!!Slide5
Intuitive or automaticProblem representation (should include context)Illness scriptsOften involves pattern recognitionContextual cuesSlide6
Expertise vs. experienced non-expertsRefining problem representationRefining illness scriptsKnowing when to invoke analytic reasoningSlowing down when you should: a new model of expert judgmentMoulton Acad Med 2007 vol. 82 (10
Suppl
) pp. S109-16Slide7
My pharyngitis evolutionHow my problem representation and illness scripts evolved over 30 yearsThe following cases tell a cautionary taleSlide8
1981Problem representation:Does the adult pharyngitis ER patient have a strep throat?Context:No rapid tests yetMinimal chance for follow-upIllness scriptTreat strep throat patients to prevent acute rheumatic feverStrep throat patients look sicker (on average)Slide9
Group A Strep Prediction Model286 consecutive adult ED patients2 throat swab cultures – with specific typing of groups (A,B,C and G)
Logistic regression model
developed
Centor. MDM – 1981.Slide10
The MODELFour factors, equally weightedTonsillar exudatesSwollen, tender anterior cervical nodesLack of cough
FeverSlide11
Probability Estimates
History of fever
Tonsillar exudates
Swollen, tender, anterior cervical nodes
Lack of coughSlide12
2000Problem representation:Provide the four clinical factorsContext:Want to treat strep throat – several reasonsBut we may also want to treat group C strepSlide13
Illness script 2000Use the score to estimate strep probabilityWe should give strep throat patients penicillinTo prevent acute rheumatic feverTo decrease peritonsillar abscessTo decrease symptom durationTo decrease contagionSlide14
2000Slide15
An eponym
Adios
pharyngitis – 1993
Eponym first used 2000
The
prevailing
paradigmSlide16
The current (early 21st century) paradigm (illness script)Slide17
The current paradigmSlide18
The current paradigmSlide19
The current paradigmSlide20
2001Slide21
Pharyngitis Guideline (CDC & AAFP)
Reassure 0 + 1
Test 2
Test or treat 3 + 4Slide22
2002Slide23
Pharyngitis guidelineReassure 0 + 1
Test 2, 3 & 4
I become enraged with this quoteSlide24
Clinical Infectious Diseases 2002“We must conclude, therefore, that the algorithm based strategy proposed in the ACP-ASIM Guideline would result in the administration of antimicrobial treatment to an unacceptably large number of patients with
nonstreptococcal
pharyngitis.
”Slide25
IDSA strep pharyngitis 2012Same general message!Focus on group A strepMention but dismiss other bacteriaSlide26
Why are the conclusions different?Different focus of illness scriptsACP – more outpatient generalist focused, therefore treating the patient is the clear priorityIDSA – more societal focused – worried about creating antibiotic resistanceSlide27
Stimulus for blog & new interestSlide28
2005Slide29
a Malpractice Lawyer callsFather of 2 boys w/ documented group A strep c/o sore throatNegative rapid test -> no Rx
Patient dies 2 days later of group A strep septicemia
Do they have a case?Slide30
Mistakes Made #1Ignored the concept of pretest probability
This is a contextual error
He used intuitive diagnosis and treatment, but should have invoked analytical reasoning
But this care does follow
a guideline…
So probably no malpractice caseSlide31
2006Slide32
Morning Report Presentation
ER Visit
Day 3
ER Visit
Day 5
ER Visit
Day 9
Presents to ER Negative Rapid Test
Returns to ER
Worsening symptoms –
Negative Rapid Test
Severe (10/10) throat pain, high fever, and hoarseness
Day 1
30 yo WF
Symptomatic treatment
both timesSlide33
Case ContinuedPhysical examination T: 101°
HR:
101
RR:
18
BP:
122/78
Prominent exudates, non-displaced uvula
Anterior cervical nodes
Diffuse anterior neck edema
Diffuse moderate ant neck tenderness
Pharyngitis score = 4Slide34
Laboratory Data Negative rapid test Negative mono spot test
CT of neckSlide35
Enlarged Palatine tonsilsSlide36
Diagnostic Studies Culture – negative GC & chlamydiaRapid flu test
EBV and CMV titers -
HIV -
Throat culture grew group C strep
Full recovery with 7 days of antibiotics Slide37
Differential of worsening pharyngitisFalse negative rapid test Sensitivity in practice - ~75%
NGA strep (group C > group G)
GC pharyngitis
Infectious Mononucleosis
Acute HIV infection
Shah. JGIM – 2007.Slide38
Differential continuedPeritonsillar abscess
Lemierre’s
syndrome
F
necrophorum
bacteremic
pharyngitisSlide39
Mistakes Made #2First ER visit acceptable – used intuitionSecond ER visit – context should have triggered analytic reasoning
Decisions based on test results
Rather than patient presentationSlide40
Lesson learned from Case #2No previous illness script for “worsening pharyngitis”Worsening pharyngitis is no longer “just a sore throat” ANDIt REQUIRES analytic reasoningSlide41
Increasing interest in LemierreRepeated blog entriesMany comments including the mother of a Lemierre syndrome survivor
Multiple emails
Multiple newspaper linksSlide42
2008Slide43
Justin Rodgers
Day 1 – sore throat
Day 2 – doc started Z-pack
Day 3-6 – fevers to 102 pain & swelling Right neckSlide44
Justin Rodgers
Admitted for metastatic lung abscesses
Day 9 – blood grew Fusobacterium
He died after 3 weeks in the ICUSlide45
Lemierre’s SyndromeSyndrome known since the early 1900s1936 Lancet by A. Lemierre
Bacillus funduliformis
in 1930
Fusobacterium necrophorum (@ least 80%)
Lemierre. Lancet – 1936.Slide46
Lemierre’s Presentation
Sore throatSlide47
Lemierre’s Presentation
Sore throat
4-5 days
Fever & rigorsSlide48
Lemierre’s Presentation
Sore throat
4-5 days
Fever & rigors
Repeated rigorsSlide49
Lemierre’s Presentation
Sore throat
4-5 days
Fever & rigors
Repeated rigorsSlide50
Lemierre’s Presentation
Sore throat
4-5 days
Fever & rigors
Repeated rigors
Metastatic abscessesSlide51
Mistakes Made #3Used azithromycin rather than penicillinPrimary physician
stayed in automatic mode despite:
worsening course
neck swelling
bacteremic
symptomsSlide52
Tyranny of a term“just a sore throat”
Never considered switching to analytic reasoningSlide53Slide54
The Danish Experience 90-95Incidence of necrobacillosis1.5 / million / yr
Incidence of Lemierre’s
0.8 / million / yr
All 24 patients with Lemierre’s were young and previously healthy
Pre-hospital delay = increased morbidity
Hagelskjaer.
Eur J Clin Microbiol Infect Dis -
1998. Slide55
The Danish Experience 98-013 yr prospective study
58 patients with
Lemierre’s
3.6 cases / million /
yr
14.4 cases / million /
yr
(or 1 in 70,000) for the age group 15-24
Hagelskjaer. Eur J Clin Microbiol Infect Dis - 2008.Slide56
Time for analytic reasoning!Slide57
Illness scriptIs our illness script wrong?Should we add fuso pharyngitis to our illness script?Slide58
Is Fuso pharyngitis as dangerous as strep pharyngitis?Slide59
What data did I need?Relative prevalence of strep and
fuso
pharyngitis
Risk of ARF from strep
Risk of Lemierre from
fuso
Outcomes of ARF & LemierreSlide60
Fusobacterium necrophorumDeduction –>
F. necrophorum
causes pharyngitis
Lemierre’s follows sore throats
4 studies support
F. necrophorum
-> endemic pharyngitis
But no clinical dataSlide61
Fusobacterium pharyngitisLikely cause of endemic pharyngitisMore common in adolescents and young adults - ~ 10% incidence
Possible synergistic action with
EBV
Group C
No current diagnostic test
Differential for worsening pharyngitisSlide62
2009Slide63
Lemierre’s Risk for adolescents
6% pharyngitisSlide64
Lemierre’s Risk for adolescents
6% pharyngitis
60,000/
1 millionSlide65
Lemierre’s Risk for adolescents
6% pharyngitis
60,000/
1 million
6000
F. necro
/
1 millionSlide66
Lemierre’s Risk for adolescents
60,000/
1 million
6000
F. necro
/
1 million
14.4 Lemierre’s/
1 million
6% pharyngitisSlide67
Lemierre’s Risk for adolescents
6% pharyngitis
60,000/
1 million
6000
Fuso
/
1 million
14.4 Lemierre’s/
1 million
1/400
F.
pharyngitis ->
Lemierre’sSlide68
Lemierre’s mortality estimate
Sources
UK 89
Denmark 98
Riordan 03
Denmark 08
Total
Pts.
29
15
222
37
303
Deaths
1
0
11
1
13
Rate
4.5%
0
4.9%
2.7%
4.7%Slide69
Why expand the pharyngitis paradigm!
1 million adolescents with pharyngitis
Group A
100,000
F. necro
100,000
ARF
50-100
Lemierre’s
250
Complex ARF
5-10
Disability
20
Death
0.5- 1
Death
11Slide70
3 effects of bacterial pharyngitis explain the scoreInflammatory responseFebrile responseLack of viral symptomsSlide71
Questions concerning the scoreWhat other than GAS caused the 3s and 4sGroup C (or G) dataNow ? Fusobacterium necrophorumSlide72
Group C/G pharyngitis1990 – group C/G pharyngitis occurs approximately ½ as often as group A in adolescents and young adultsMuch less common in pre-adolescentsThe Zwart treatment studySlide73
Zwart Penicillin StudyCulture rates for A, C and GAdult pharyngitis patients > controls
Faster symptom relief
7d penicillin > 3d penicillin or placebo
Group A – 2 day effect
Group C – 1 day effect
Zwart. BMJ - 2000.Slide74
Pharyngitis – adolescents are differentPre-adolescentsHigher rate of GASGCS less frequentEBV does not cause infectious mononucleosisF. necrophorum rare
Adolescents
Less GAS and lower carrier rate
GCS more frequent
Frequent inf. Mono.
F. necrophorum common with high carrier rateSlide75
Fusobacterium Study Demographics (n=312)CharacteristicValue
Mean age (SD),
y
22.3 (3.1)
Age,
n (%)
15
-
20
y
111 (35.6)
21 - 25
y
141 (45.2)
26 - 30
y
60 (19.2)
Women,
n (%)
232 (74)
Race,
n (%)
White
231 (74)
Black
43 (14)
Asian
21 (7)
Hispanic
5 (2)
Other or not known
12 (4)Slide76
Centor Score by Bacteria (n=312)GAS p < 0.001
Chi square for trend
Centor
ScoreSlide77
Centor Score by Bacteria (n=312)GCS p < 0.001
Chi square for trend
Centor
ScoreSlide78
Centor Score by Bacteria (n=312)Fuso p < 0.001
Chi square for trend
Centor
ScoreSlide79
Centor Score by Bacteria (n=312)Any p < 0.001
Chi square for trend
Centor
ScoreSlide80
ConclusionsAs the score increases, the likelihood of a bacterial infection increases significantlyFusobacterium pharyngitis has a similar presentation to both group A strep and group C/G strep pharyngitisSlide81
SpeculationOne should consider empiric treatment of at least scores of 3 and 4 and possibly 2 in the 15-30 age groupWould likely decrease suppurative complicationsDo not use macrolides in this age group for empiric treatmentSlide82
Take home pointsF necrophorum causes endemic pharyngitis
Avoid macrolides for empiric treatment
Pharyngitis
normally
resolves in 3-5 days
Red flags
Neck swelling
High fever, rigors, night sweats
For
bacteremic
symptoms :
penicillin and metronidazole
clindamycinSlide83
Pharyngitis illness script 2051Pharyngitis score indicates bacterial pharyngitisBoth strep A & C and fuso pharyngitis deserve antibioticsWhen symptoms worsen, switch to analytic reasoningWe need to revise guidelines to consider more than GASSlide84
ReferencesSlides and references available upon request
rcentor@uab.edu