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We thank Dr. Schmid et al. for their very topical and valuable information on the management of sore throat in the context of the COVID-19 pandemic. Since the process of developing a clinical practice guideline extends over a period of several years, experiences from the COVID-19 pandemic could not be incorporated into the recommendations. The paragraph on the COVID-19 pandemic in the short version for the Deutsche Ärzteblatt (1) was intended to provide up-to-date cross-references for specific recommendations on the management of SARS-CoV-2.

The risk of suppurative complications of bacterial tonsillopharyngitis is generally considered to be very low. In a UK cohort study (11 950 GP patients with acute tonsillopharyngitis), the complication rate was just 1.4%. This low risk was only minimally reduced by antibiotic treatment (number needed to treat of 193). Invasive streptococcal infections, such as streptococcal sepsis, were not observed in this large cohort (2).

Based on this and comparable data, the clinical practice guideline supports an approach that in primary care settings antibiotic treatment can be omitted in the absence of red flags, even if the clinical findings make the diagnosis of streptococcal tonsillopharyngitis high likely. However, to ensure that rare complications, such as streptococcal sepsis, are not overlooked, the treatment algorithm highlights the need to very regularly check for clinical signs of severe systemic disease. It cannot be excluded that under pandemic conditions it is more difficult to follow such an approach and that clinical signs of early sepsis are misinterpreted as COVID-19.

Data which would allow to estimate the individual risk of invasive streptococcal disease in patients with clinical tonsillopharyngitis in combination with the detection of SARS-CoV-2 have not yet become available. Schmidt et al. highlight the unusually high number of cases with group a Streptococcus sepsis in their center during the first wave of the pandemic. Other viral infections, such as varicella infection, have already been described as risk factors for invasive streptococcal infections (3). Whether the same also applies to SARS-CoV-2 infection is definitely an important research question. In a nationwide survey in Germany, we have at least not in children observed any significant differences in the number of cases of invasive infection with beta-hemolytic streptococci reported in 2020 versus 2019 (4).

We thank Prof. Biersack for his important comment on subacute granulomatous thyroiditis (De Quervain‘s thyroiditis). The clinical practice guideline explicitly emphasizes the need for clinical examination in patients with the seemingly trivial symptom of sore throat. In addition to severe courses of the disease, this approach ensures that alternative conditions, such as subacute thyroiditis, are noticed. The characteristic clinical signs of subacute thyroiditis (induration, swelling, marked tenderness of the thyroid gland) enable attentive examiners to distinguish it from tonsillopharyngitis. We will look to add a note on De Quervain‘s thyroiditis to the guideline in future updates.

DOI: 10.3238/arztebl.m2021.0247

Corresponding author

Dr. med. Jan Hendrik Oltrogge

Institut und Poliklinik für Allgemeinmedizin

Universitätsklinikum Hamburg-Eppendorf (UKE)

Hamburg, Germany

j.oltrogge@uke.de

Conflict of interest statement

The authors of all contributions declare no conflict of interest.

1.
Krüger K, Töpfner N, Berner R, Windfuhr J, Oltrogge JH: Clinical practice guideline: Sore throat. Dtsch Arztebl Int 2021; 118: 188–94 VOLLTEXT
2.
Little P, Stuart B, Hobbs FDR, et al.: Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis 2014; 14: 213–9 CrossRef
3.
Imöhl M, van der Linden M, Reinert RR, Ritter K: Invasive group A streptococcal disease and association with varicella in Germany, 1996–2009. FEMS Immunol Med Microbiol 2011; 62: 101–9 CrossRef MEDLINE
4.
Universitätmedizin Mainz: Erhebungseinheit für seltene Erkrankungen.
ESPED-Jahresberichte. www.unimedizin-mainz.de/esped/ergebnisse/berichte.html (last accessed on 17 May 2021)
1.Krüger K, Töpfner N, Berner R, Windfuhr J, Oltrogge JH: Clinical practice guideline: Sore throat. Dtsch Arztebl Int 2021; 118: 188–94 VOLLTEXT
2.Little P, Stuart B, Hobbs FDR, et al.: Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis 2014; 14: 213–9 CrossRef
3.Imöhl M, van der Linden M, Reinert RR, Ritter K: Invasive group A streptococcal disease and association with varicella in Germany, 1996–2009. FEMS Immunol Med Microbiol 2011; 62: 101–9 CrossRef MEDLINE
4.Universitätmedizin Mainz: Erhebungseinheit für seltene Erkrankungen.
ESPED-Jahresberichte. www.unimedizin-mainz.de/esped/ergebnisse/berichte.html (last accessed on 17 May 2021)

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