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McXtra Care Newsletter | November 2020

Section A

MAIN FEATURE

SORE THROAT: Causes and symptoms

Most people have experienced episodes of sore throat, that manifest as pain especially on swallowing, hoarseness, or an itchy/unpleasant feeling in the throat. The most common cause is an infection, though non-infectious causes may also be present.

INFECTIONS

In 90% of adults and 60% of children, throat infections (pharyngitis) are caused by viruses, the rest being due to bacteria. The spread is through air droplets especially in poorly ventilated/crowded areas from coughing and sneezing, or by unwashed hands.

Viral sore throat is more commonly associated with a dry cough, hoarseness and symptoms of cold like sneezing, runny nose and nasal congestion. Fever and headache may be present in some cases. Viruses causing sore throat are mainly those of common cold, Flu and COVID. Sore throat may sometimes also be part of the symptoms of other viral infections like measles, mumps and infectious mononucleosis.

Bacterial sore throat is most commonly caused by Streptococcus pyogenes, also called Group A beta-hemolytic Streptococcus (Strept sore throat). This is seen more commonly in children. There is usually significant throat pain and difficulty in swallowing, and many children have trouble eating due to this. Accompanying fever, body ache and malaise (discomfort and weakness) is common. Vomiting, diarrhea and abdominal pain may also be present in children. There can be enlargement of the tonsils and the lymph nodes of the neck.

A clinical examination can usually differentiate a bacterial sore throat from a viral one, as in bacterial infections there is significant redness and swelling in the back of the mouth, and enlarged tonsils (tonsillitis) often with visible pus or white spots. The swollen lymph nodes can also be felt and maybe tender (painful to touch). However, if the diagnosis is in doubt, rapid antigen tests with throat swabs can be done for Strept, Flu and COVID to get a confirmed diagnosis.

Strept sore throat can sometimes lead to complications in other parts of the body like glomerulonephritis (kidney inflammation) and rheumatic fever (can damage heart valves). It can also cause pus pockets called abscesses in the throat and tonsils. Therefore, it should be diagnosed promptly and treated with appropriate antibiotics. Some other bacteria like Streptococcus pneumoniae, Moraxella and Hemophilus can also cause sore throat along with ear infection and pain.

Rarely, a fungus called Candida can cause sore throat in people who have compromised immunity. Characteristic white patches (thrush) are seen on examination.

NON-INFECTIOUS CAUSES OF SORE THROAT

These include:

– Allergies to substances like pollen, dust mites, fungal molds or animal hair – These can cause nasal symptoms (allergic rhinitis), red eyes, as well as sore throat due to direct inflammation or backward dripping of mucus from the nose (postnasal drip).
– Tobacco smoke (active and passive) and other environmental irritants like exhaust, and chemicals.
– Acidity due to acid reflux or eating very spicy foods.
– Mouth breathing and snoring causing dryness of the throat.
– Intense screaming, shouting and throat strain.
– Throat cancers (rare).

Section B

TRENDING FEATURE

HEALTH measures for sore throat

Observing proper hygiene like washing/sanitizing hands regularly, covering mouth while sneezing/coughing, and wearing a mask in public places during a pandemic like COVID, can decrease transmission of such infections.

Strept/bacterial sore throat should be diagnosed and treated promptly with appropriate antibiotics in the recommended dose and duration, prescribed and monitored by the physician. In most cases, viral sore throat resolves on its own, and antibiotics have no role.

Supportive and symptomatic treatment for sore throat is given to improve comfort, which includes:

Warm fluids and soft diet
Rest
Medications for fever, inflammation and pain (NSAIDs- Paracetamol combinations with Ibuprofen or Diclofenac)
Soothing and anesthetizing lozenges for sucking and soothing effect.
Gargling with salt water, or anti-inflammatory/antiseptic agents like benzydamine, menthol, chlorhexidine, povidone-iodine, etc. (some of these agents are also available as throat spray and in combinations).
Natural substances like turmeric, ginger, honey, Indian gooseberry (amla) and Indian basil (tulsi) are soothing, and also good for general health and immunity. They can be consumed by soaking in warm water, or as market preparation of herbal tea.
Vitamin-Mineral supplements (containing vitamin C and zinc) may be given for general health and immunity
Medicines for nasal congestion, sneezing/irritation, and cough may be added when present in required cases to enable good sleep and rest. (These include antihistamines, decongestants, mucolytics, and antitussives)
Antibiotics, as mentioned are to be given in bacterial sore throat

COVID-19 or Flu (Influenza) may require hospitalization in cases where the symptoms are severe, there is accompanying breathlessness, or presence of co-morbidities like increased age, diabetes, cardiovascular disease (CVD), high BP, kidney or liver problems, asthma or chronic bronchitis, or conditions causing low immunity.

Prompt medical consultation should be taken if the sore throat is accompanied by any of the following

Difficulty in eating or drinking,
Drooling of saliva
Breathlessness (Difficulty in breathing or noisy breathing)
Fever above 101 F/ 38.3 C, or presence of chills
Disorientation or confusion
Ear pain

Section C

SPECIAL FEATURE

Appropriate antibiotic use: preventing resistance

WHAT IS RESISTANCE?

Resistance is when a micro-organism initially susceptible to an antibiotic is now no more affected by it. This is a huge challenge that Antibiotics today face due to large scale usage. It’s a constant one-upmanship fight between humans and the bacteria and the bacteria seem to be way smarter!

The bacteria develop different types of ‘skills’ to prevent the antibiotic from being effective on them- like pumps on their cell membrane to throw the antibiotic out or prevent entry, or slightly change/modify the enzymes, protein or target structure on which the antibiotic acts. They can also release enzymes which can inactivate or break the chemical structure of the antibiotic. (Such antibiotics have to be combined with the inhibitors of these bacterial enzymes like Amoxycillin plain versus Amoxyclav which is a combination of Amoxycillin with bacterial beta lactamase enzyme inhibitor called Clavulanate).

Some bacteria maybe smarter than the others and acquire one of the resistance mechanisms very fast. Many strains of bacteria like Staphylococcus (called MRSA and VRSA), Streptococcus group, Klebsiella, Pseudomonas and Acinetobacter along with TB causing bacteria (Mycobacterium) and Typhoid bacteria (Salmonella typhi) have shown high degree of resistance to several antibiotics and are becoming tougher to treat with need for newer antibiotics to be developed.

The minimum concentration at which the antibiotic kills the majority of a bacterial population is called the Minimum Inhibitory/Lethal concentration (MIC or MLC) which is calculated for every antibiotic for each kind of bacteria. The dose and frequency with which antibiotics are given is formulated on the basis of maintaining the concentration well above the MIC. Chances of resistance increase when bacteria are frequently exposed to antibiotics at a lower concentration, which is not enough to kill them but gives them an opportunity to start adapting to prevent the effect of that antibiotic on them. This makes each subsequent generation of the bacteria gets more and more resistant to that antibiotic.

This is why more exposure of the community to an antibiotic, indiscriminate usage or overuse, extensive use in livestock, inappropriate duration and dose of use, and lack of hygienic practices and health regulations leads to development of resistance of bacteria to many antibiotics. Most common infections like cold, cough and mild fever are caused by viruses and do not require antibiotics which are ineffective against viruses. However, antibiotics are often prescribed in practice for the same, contributing to the growing problem of resistance.

WAYS TO REDUCE RESISTANCE

Take antibiotics only with a doctor’s prescription after examination of your current condition. Do not use past prescriptions for similar symptoms to start antibiotics on your own.
Most common colds, fevers and coughs are viral in nature and become okay in 3-5 days without any need or use of antibiotics. Rest, good nutrition and hydration along with simple lifestyle measures ensure recovery. Do not resort to or insist on using antibiotics expecting ‘fast’ results
Always take the correct dosage strength as many times a day mentioned on your prescription. Do not omit or modify dosage on your own.
Complete the duration of the prescribed antibiotic course even if you feel completely recovered earlier.
Do not share your antibiotics or give leftover antibiotics to family/community members.
Do not medicate with more than one antibiotic at a time unless combinations are specifically prescribed by your doctor.
Practice hygiene like proper waste disposal, hand washing and maintaining clean surroundings to reduce infection rates.
Ensure a healthy nutritious diet at all times as this improves immunity to both prevent and fight infections.
Before starting antibiotics empirically, it is wise to have a sample taken from the infected site (cost and feasibility permitting in developing countries), to study the causative bacteria and its sensitivity to various antibiotics.
Regular notification of resistance patterns to health authorities by doctors helps to regulate usage and select appropriate antibiotics for a region.

Government and Health Authorities are now striving in many countries to institute plans, monitor effectively and put regulations in place to reduce the rising Antibiotic resistance menace.