An untreated throat infection can turn into a fatal bacterial cluster bomb

General practitioners in Denmark conduct a total of 1.2 million examinations for throat infection every year, which means that one in five of us make one visit a year to the doctor due to this unpleasant condition. But what is the procedure GPs follow when examining their patients? And which treatment do they usually prescribe?

Consultant at the Ear-Nose-Throat Department at Aarhus University Hospital Tejs Ehlers Klug decided to investigate together with three of his colleagues. Their study, based on responses from 266 GPs in Central Denmark Region, was recently published in the scientific journal BMC Medical Practice.

‘Throat infections are often considered an extremely banal condition, but this is not necessarily the case. They can be decidedly life-threatening, and in Denmark alone they are the cause of around 2,000 cases of throat abscesses which need to be surgically removed. Throat infections – and their treatment – are actually very complex. And we point this out in our study,’ says Tejs Ehlers Klug, who received funding from the Lundbeck Foundation for this project.

Standard procedure
The Danish Organisation of General Practitioners has prepared a set of guidelines – a kind of standard procedure – outlining the organisation’s opinion on how to diagnose and treat a patient who turns up in a GP’s surgery with symptoms of a throat infection.

However, based on the responses of the 266 GPs in Central Denmark Region, this new study indicates that only one per cent of Danish GPs follow the guidelines to the letter. 99 per cent use some modification of the method.

The question is whether this is a problem. ‘And there’s no clear answer,’ explains Tejs Ehlers Klug:

‘In most cases, the GP will perform a quick test consisting of a swab of the throat to check whether the patient has a Streptococcus A infection. If this on-the-spot test shows that this is the case, the GP will usually prescribe penicillin as a standard treatment – or a macrolide if the patient is allergic to penicillin.’

However, the new study shows that, in many cases, doctors even prescribe antibiotics if the Streptococcus A test is negative. The explanation for this is that a range of other bacteria may be at work – bacteria which are not detected by the Streptococcus A test. The GP’s reasoning may be that the patient could have some other type of infection and, to be on the safe side, it would be best to prescribe antibiotics.

Nonetheless, in Tejs Ehlers Klug’s opinion, this approach can easily be inappropriate:

‘Because it stands to reason that, to some degree or other, antibiotics will be prescribed without cause. For instance, if the patient has a virus, this can’t be treated with antibiotics. And, when it comes down to it, this uncertainty simply raises the incidence of antibiotic resistance, which inevitably increases the more antibiotics we prescribe.

‘Therefore, we really need to design a new test which will pick up a range of the most important – that is, the most undesirable – bacteria which may be at work when a patient has a throat infection,’ says Tejs Ehlers Klug.

Developing this test will require a lot of work because, in addition to Streptococcus A, it will need to be able to identify Streptococcus C and G and Arcanobacterium – and, not least, Fusobacterium, which according to Tejs Ehlers Klug is one of the worst offenders when it comes to throat infections.

Throat abscesses and death
Fusobacteria can be combated with antibiotics, but if the infection is not treated in time it can have serious consequences – such as peritonsillar abscesses. Once these have taken hold they need to be removed with a scalpel.

Tejs Ehlers Klug goes on to explain that fusobacteria also have a nastier – directly life-threatening – side:

‘They can cause Lemierre’s syndrome. Fortunately, this is exceedingly rare. There are probably only five to ten cases a year in Denmark. And we usually manage to treat them so that the patient survives, but every few years Lemierre’s syndrome causes a death here.’

When fusobacteria combine with something that started as a seemingly innocent throat infection and develop into Lemierre’s syndrome, it quite literally creates an insidious ‘cluster bomb of bacteria’.

‘The fusobacteria spread to the jugular vein and form a blood clot,’ Tejs Ehlers Klug explains.

‘The clot contains fusobacteria and, at some point, the thrombosis begins to discharge small clots into the bloodstream. These can end up anywhere and in many different organs. It’s extremely dangerous.’

For some reason, as yet unexplained by research, these bacteria cluster bombs predominantly affect young people, between the ages of 15 and 25.

It also seems that thrombosis produced by fusobacteria is an increasing problem, which is causing concern in the USA. And researchers have no idea why these bacteria cluster bombs appear to be increasing in prevalence.