Acute Pharyngitis: Tips From the Author of the Centor Criteria

This transcript has been edited for clarity.

Christopher J. Chiu, MD: I'm Christopher Chiu, and we are The Cribsiders. In our pediatric medicine podcast, we interview leading experts to bring you clinical pearls and practice-changing knowledge, and we answer leading questions about core topics in pediatric medicine.

Justin L. Berk, MD, MPH, MBA: I'm Justin Berk, your co-host for today. We had a wonderful episode talking about acute pharyngitis with Dr Robert Centor. Dr Centor is a professor emeritus at the University of Alabama at Birmingham. He is the host of the Annals On Call podcast. He is also an enormous Twitter influencer with his handle @medrants. Most important for this episode, he is the creator of the eponymous Centor criteria for the risk stratification of bacterial pharyngitis.

Chiu: To review, the Centor criteria include cervical lymphadenopathy, absence of cough, fever, and tonsillar exudates.

The modified Centor criteria — or the McIsaac criteria — score adds a point if the patient is younger than 15 years of age. Remember that exudates are the greatest predictor, and consider pain with swelling as a proxy for exudates when you are doing a telemedicine visit. In the original study, reported fever was as accurate as measured fever. Other things to remember in your physical exam, in addition to the Centor criteria, are scarlatiniform rash and palatal petechiae.

Berk: In addition to all of these physical exam findings, we talked about the sensitivity and specificity of rapid tests. A rapid strep test has a good specificity, meaning that if it's positive, you do likely have group A strep (GAS). But it's not a very sensitive test; a negative rapid test does not rule out strep.

There are six real reasons to treat GAS. According to Dr Centor, none of them are honestly that impressive.

The first is to decrease acute rheumatic fever, which is pretty rare in the United States. Antibiotics, though, do not go as far as things like general sanitation [in preventing this complication], so I don't know if this is a great reason to treat it anymore.
It can prevent death from sepsis. But when was the last time you saw anyone with GAS sepsis? It's pretty rare. So that is an uncommon reason to treat as well.
You can get some mild symptom improvement in adolescents and adults. That is helpful, but it really only reduces symptoms by about half a day.
You can decrease transmission to other household contacts. Treating a patient who has GAS can reduce the likelihood of transmission to other people in the house by about half.
It can reduce suppurative complications like mastoiditis, acute otitis media, and peritonsillar abscess. The number needed to treat [to reduce these complications] approaches close to 200, so this is one of those situations requiring a risk-benefit analysis to determine whether treatment is worth the side effects of antibiotics.
Finally, and maybe the most logistically reasonable, is that schools often require patients to be on antibiotics before they can return to school.

Those are the major reasons why you might want to treat GAS, but the dogma of treating is actually now being challenged.

Chiu: Current guidance is more than just for strep; it also includes Fusobacterium. Remember, in adolescents, Fusobacterium is the number-one cause of peritonsillar abscess. Fusobacterium can cause infectious thrombophlebitis, also known as Lemierre's syndrome. It is more common than acute rheumatic fever and used to be more deadly; [mortality] used to be about 90%, but now it's closer to 5%. Red flags include rigors, unilateral neck pain, persistent symptoms after 5 days, and shortness of breath, mostly from septic emboli.

Berk: We learned a lot. We hope you can join us to learn more on The Cribsiders episode on acute pharyngitis with Dr Robert Centor. You can find this episode on any of your favorite podcast apps, or check out our website. If you'd like to reach us, send us an email at thecribsiders@gmail.com. We really appreciate you guys tuning in and hope to see you in the future.

Chris Chiu, MD, is assistant professor at The Ohio State University, where he is also the physician lead at OSU's Outpatient Care East Clinic and serves as the assistant clinical director for the internal medicine residency. He is an Air Force veteran and a self-proclaimed gadget geek. Follow him on Twitter

Justin Berk, MD, MPH, MBA, is assistant professor of medicine and pediatrics at the Warren Alpert School of Medicine at Brown University. He is a clinical educator active in ambulatory and inpatient care and pediatrics. He enjoys coffee, thinking about hiking, and being a generalist. Follow him on Twitter

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