Pharyngitis

To the editor,

We read with interest the article by Skyes et al. on Pharyngitis. This is a common problem in primary care and should be a core competency of any family doctor. We welcome this review.

We are most concerned about the recommendations regarding the treatment of bacterial pharyngitis and alternatives advised in case of penicillin allergy.
Pen V is the drug of choice for Group A strep due to its narrow spectrum. It was not mentioned in this review. Benzathine Pen G IM is the drug of choice for syphilis and is hard to get as it is supplied only by public health in NS. Community pharmacists appear unable to order it through their wholesalers (from personal communications).

The alternatives to Penicillin in penicillin allergic individuals advised by the authors include the third generation cephalosporins cefdinir and cefpodoxime. According to the Health Canada Drug Product Database cefdinir is not available in Canada and cefpodoxime is only approved and marketed for veterinary use. These unusual recommendations are likely due to the authors overreliance on Korean Guidelines for recommendations.(1) Pen V is not available in Korea and presumably the two recommended third generation cephalosporins mentioned are.

In this review cephalexin is wrongly listed as a second generation cephalosporin, it is in fact a first generation cephalosporin.

It is ampicillin that causes a non-hypersensitivity rash in >70% of patients with EBV infection and amoxicillin causes the rash in 30% (2)

Penicillin allergy is a topic well covered in a recent NEJM review. (3) In the case of a high risk Type 1 reaction (anaphylaxis) it has been our practice to avoid all B lactam antibiotics and refer the patient to an allergist for further evaluation. For less serious reactions we are using another beta-lactam guided by side chain analysis realizing of course that most patients who historically think they have a penicillin allergy actually do not.(4)

We believe that a review that reflected North Amaerican antimicrobial guidelines and recommended antimicrobials approved and marketed in Canada would be better suited as a reference for Canadian physicians.

Signed,
O’Dea, M. BSc(Pharm), Buhariwalla, F. MD CCFP(EM) FCFP

1Yoon YK, Park CS, Kim JW, Hwang K, Lee SY, Kim TH, et al. Guidelines for the antibiotic use in adults with acute upper respiratory tract infections. Infect Chemother 2017;49(4):326-52.
2 Incidence of Rash After Amoxicillin Treatment in Children With Infectious Mononucleosis
Aluma Chovel-Sella, Amir Ben Tov, Einat Lahav, Orna Mor, Hagit Rudich, Gideon Paret, Shimon Reif
Pediatrics May 2013, 131 (5) e1424-e1427; DOI: 10.1542/peds.2012-1575
3 Mariana Castells, David A. Khan, Elizabeth J. Phillips. Penicillin Allergy. N Engl J Med 2019; 381:2338-2351
4Antibiotics Why and Why Not 2018 Dalhousie CPD Academic Detailing Service, November 2018 http://www.medicine.dal.ca/departments/core-units/cpd/programs/academic-...