Management Of Pharyngitis Research Articles

Diagnosis and Management of Pharyngitis in a Pediatric Population Based on Cost-Effectiveness and Projected Health Outcomes

Pharyngitis is a common childhood complaint. Current management for children and adolescents includes 1 of 6 strategies, ie, (1) observe without testing or treatment, (2) treat all suspected cases with an antibiotic, (3) treat those with positive throat cultures, (4) treat those with positive rapid tests, (5) treat those with positive rapid tests and those with positive throat cultures after negative rapid tests, or (6) use a clinical scoring measure to determine the diagnosis/treatment strategy. The sequelae of untreated group A hemolytic streptococcal (GAS) pharyngitis are rare, whereas antibiotic treatment may result in side effects ranging from rash to death. The cost-utility of these strategies for children has not been reported previously. A decision tree analysis incorporating the total cost and health impact of each management strategy was used to determine cost per quality-adjusted life-year ratios. Sensitivity analyses and Monte Carlo simulations assessed the accuracy of the estimates. From a societal perspective with current Medicaid reimbursements for testing, performing a throat culture for all patients had the best cost-utility. For private insurance reimbursements, rapid antigen testing had the best cost-utility. Observing without testing or treatment had the lowest morbidity rate and highest cost from a societal perspective but the lowest cost from a payer perspective. The model was most sensitive to the incidence of acute rheumatic fever and peritonsillar abscess after untreated GAS pharyngitis. Monte Carlo simulations demonstrated considerable overlap among all of the options except for treating all patients and observing all patients. Observing patients with pharyngitis had the lowest morbidity rate. The costs of this option were primarily from parental time lost from work. Before recommending observation rather than treatment of GAS pharyngitis, accurate estimates of the risk of developing acute rheumatic fever and peritonsillar abscess after GAS pharyngitis are needed.

Management of Acute Pharyngitis in the ER: Not According to Hoyle

Management of Acute Pharyngitis in the ER: Not According to Hoyle

Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults—Correction

Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults—Correction

The appropriate management of pharyngitis in children and adults

Acute pharyngitis, or the complaint of a sore throat, is one of the most common illnesses for which both adult and pediatric patients seek medical care from primary care physicians. In the USA, acute pharyngitis accounts for 1–2% of all visits to outpatient departments, physician offices and emergency departments. There are multiple etiologic agents that can cause pharyngitis, and strategies for diagnosis and treatment should be directed at identifying those causes of pharyngitis that require antimicrobial therapy. In some cases, the decision as to which patients to treat with antibiotics remains difficult. This article reviews some of the various causes of pharyngitis and the available therapeutic options.

A clinical decision rule for management of streptococcal pharyngitis in low-resource settings

Most of the world's children live in regions where laboratory facilities are not available. In these regions, clinical prediction rules can be useful to guide clinicians' decisions on antibiotic therapy for streptococcal pharyngitis, and to reduce routine presumptive antibiotic therapy for all pharyngitis.Prospective cohort study to assess diagnostic signs and develop a prediction rule. Bivariate and multivariate analyses were used to develop clinical rules. Participants were 410 children in Cairo, Egypt, aged from 2 to 12 y, presenting with complaint of sore throat and whose parents provided consent. Main outcome measures included presence of signs and symptoms, and positive group A beta hemolytic streptococcal (GABHS) culture.101 (24.6%) children had positive GABHS culture. Pharyngeal exudate, tender or enlarged anterior cervical lymph nodes, season, absence of rash, or cough or rhinitis were associated with positive culture in bivariate and multivariate analyses. Three variables (enlarged nodes, no rash, no rhinitis), when used in a cumulative score, showed 92% sensitivity and 38% specificity in these children.The proposed three-variable clinical prediction rule for GABHS may be useful when diagnostic laboratories are not available. In this setting, the rule identified more than 90% of true cases. Compared to universal treatment of all pharyngitis, the rule will reduce antibiotic use in GABHS-negative cases by about 40%.

A clinical decision rule for management of streptococcal pharyngitis in low‐resource settings

Most of the world's children live in regions where laboratory facilities are not available. In these regions, clinical prediction rules can be useful to guide clinicians' decisions on antibiotic therapy for streptococcal pharyngitis, and to reduce routine presumptive antibiotic therapy for all pharyngitis. Prospective cohort study to assess diagnostic signs and develop a prediction rule. Bivariate and multivariate analyses were used to develop clinical rules. Participants were 410 children in Cairo, Egypt, aged from 2 to 12 y, presenting with complaint of sore throat and whose parents provided consent. Main outcome measures included presence of signs and symptoms, and positive group A beta hemolytic streptococcal (GABHS) culture. 101 (24.6%) children had positive GABHS culture. Pharyngeal exudate, tender or enlarged anterior cervical lymph nodes, season, absence of rash, or cough or rhinitis were associated with positive culture in bivariate and multivariate analyses. Three variables (enlarged nodes, no rash, no rhinitis), when used in a cumulative score, showed 92% sensitivity and 38% specificity in these children. The proposed three-variable clinical prediction rule for GABHS may be useful when diagnostic laboratories are not available. In this setting, the rule identified more than 90% of true cases. Compared to universal treatment of all pharyngitis, the rule will reduce antibiotic use in GABHS-negative cases by about 40%.

Validity of Using an Electronic Medical Record for Assessing Quality of Care in an Outpatient Setting

We sought to evaluate the validity of retrieving data from a commercial, outpatient electronic medical record (EMR) to assess the management of pharyngitis, an important measure of quality of healthcare in pediatrics and a new measure for the Health Plan Employer Data and Information Set (HEDIS). For children ages 3-18 years, we electronically identified clinical encounters with diagnoses of pharyngitis using 3 different strategies (an EMR-based strategy, an administrative data-based strategy, and a reference strategy which used medical record review). By each strategy, we calculated the proportion of episodes of pharyngitis during 1 year for which management of pharyngitis adhered to published guidelines. Among 479 total episodes of pharyngitis, 434 (91%) were from the EMR-based strategy and 281 (59%) from the administrative data-based strategy. Review of the records (the reference strategy) found that 391 of 479 (82%) were confirmed episodes of pharyngitis. A diagnostic test for group A streptococcus (GAS) was performed at 310 of 434 (71%) of episodes identified by the EMR-based strategy and at 214 of 281 (76%) of episodes by the administrative data-based strategy (P = 0.045). By the reference strategy, a diagnostic test was done in 301 of 391 (77%); more than at episodes found by the EMR-based strategy (71%, P < 0.001). The EMR-based strategy resulted in a statistically different proportion of episodes having diagnostic testing for GAS compared with a reference strategy. Complete evaluations to validate strategies for extracting data from electronic databases are necessary before assuming that measures of quality of care will be the same regardless of the source of data.

Empirical validation of guidelines for the management of pharyngitis in children and adults.

Recent guidelines for management of pharyngitis vary in their recommendations concerning empirical antibiotic treatment and the need for laboratory confirmation of group A streptococcus (GAS). To assess the impact of guideline recommendations and alternative approaches on identification and treatment of GAS pharyngitis in children and adults. Throat cultures and rapid antigen tests were performed on 787 children and adults aged 3 to 69 years with acute sore throat attending a family medicine clinic in Calgary, Alberta, from September 1999 to August 2002. Recommendations from 2 guidelines (those of the Infectious Diseases Society of America and of the American College of Physicians-American Society of Internal Medicine/American Academy of Family Physicians/US Centers for Disease Control and Prevention) were compared with rapid testing alone, a clinical prediction rule (ie, the modified Centor score), and a criterion standard of treatment for positive throat culture results only. Sensitivity and specificity of each strategy for identifying GAS pharyngitis, total antibiotics recommended, and unnecessary antibiotic prescriptions. In children, sensitivity for streptococcal infection ranged from 85.8% (133/155; 95% confidence interval [CI], 79.3%-90.0%) for rapid testing to 100% for culturing all. In adults, sensitivity ranged from 76.7% (56/73; 95% CI, 65.4%-85.8%) for rapid testing without culture confirmation of negative results to 100% for culturing all. In children, specificity ranged from 90.3% (270/299; 95% CI, 86.4%-93.4%) for use of modified Centor score and throat culture to 100% for culturing all. In adults, specificity ranged from 43.8% (114/260; 95% CI, 37.7%-50.1%) for empirical treatment based on a modified Centor score of 3 or 4 to 100% for culturing all. Total antibiotic prescriptions were lowest with rapid testing (24.7% [194/787]; 95% CI, 21.7%-27.8%) and highest with empirical treatment of high-risk adults (45.7% [360/787]; 95% CI, 42.2%-49.3%), due to a high rate of unnecessary prescriptions in adults (43.8% [146/333]; 95% CI, 38.4%-49.4%). Guideline recommendations for the selective use of throat cultures but antibiotic treatment based only on positive rapid test or throat culture results can reduce unnecessary use of antibiotics for treatment of pharyngitis. However, empirical treatment of adults having a Centor score of 3 or 4 is associated with a high rate of unnecessary antibiotic use. In children, strategies incorporating throat culture or throat culture confirmation of negative rapid antigen test results are highly sensitive and specific. Throat culture of all adults or those selected on the basis of a clinical prediction rule had the highest sensitivity and specificity.

Role of the microbiology laboratory in diagnosis and management of pharyngitis.

The microbiology laboratory plays a very important role in the diagnosis and management of patients with pharyngitis. Arguably, it is at least as important in identifying the 70 to 80% of patients with pharyngitis who do no require antimicrobial therapy as it is in identifying patients for whom antimicrobial therapy is appropriate. One of our educational responsibilities is to inform clinicians of the importance of performing diagnostic testing to establish an accurate diagnosis. Although some guidelines now suggest that clinical criteria alone may suffice for the diagnosis of GAS infection in adults (20), this topic remains controversial. Bisno et al. (4) have stated that these new recommendations should have been tested in a clinical trial before being published. Laboratorians need to be strong advocates for both appropriate testing and judicial use of antimicrobial agents for diagnosis and management of pharyngitis. Antibiotic therapy is generally only indicated for pharyngitis caused by GAS (2, 9, 39) and the rare case caused by C. diphtheriae and N. gonorrhoeae. Additional study is needed to clarify the benefit, if any, for the diagnosis and treatment of for beta-hemolytic streptococci other than GAS. As noted by Bisno (3), the benefits of antimicrobial therapy against these organisms are currently unknown.

Cost-effectiveness of Treatment Options for Prevention of Rheumatic Heart Disease from Group A Streptococcal Pharyngitis in a Pediatric Population

Background. We set out to examine which treatment option available in the United States was most cost-effective in treating children with endemic group A streptococcal pharyngitis to prevent rheumatic heart disease. Methods. Cost-effectiveness was calculated from the societal perspective and expressed in cases of rheumatic heart disease prevented annually in the U.S. pediatric population aged 5 to 17 based on U.S. Census data. We used a decision-analysis model to assess the cost-effectiveness of five treatment options for patients with pharyngitis: (1) “treat all,” (2) “treat none,” (3) “rapid test,” where only patients with a positive rapid antigen test are treated, (4) “culture,” where only patients with a positive throat culture are treated, and (5) “rapid test with culture” or (RTCX), where confirmatory cultures are used on patients with negative rapid tests. Cost data were gathered from existing empirical data or estimated. We performed sensitivity analyses of the antigen test sensitivity and antibiotic effectiveness and examined whether changes in these variables would alter our outcome. Results. The “rapid test” was the most cost-effective option. Using “rapid tests” prevented 85 cases of rheumatic heart disease annually and cost society $727,000 per case prevented. Performing throat cultures instead of “rapid tests” would pick up an additional 11 cases of rheumatic heart disease but would cost $13.7 million for each of these additional cases prevented. The current standard of using throat cultures as a confirmatory test on patients with a negative “rapid” test would detect an additional 21 cases of rheumatic heart disease but cost society an additional $8 million per case prevented. Conclusions. To reduce the incidence of rheumatic heart disease cost-effectively, the management of pediatric pharyngitis may best be accomplished by using antigen testing. The added costs associated with the remaining treatment options may not be justified, especially, as the sensitivity of the antigen tests continues to improve and closely approaches the sensitivity of the practice standard, throat culture.

Diagnosing streptococcal pharyngitis in the emergency department: Is a sore throat score approach better than rapid streptococcal antigen testing?

Reducing the number of unnecessary antibiotic prescriptions given for common respiratory infections has been recommended as a way to limit bacterial resistance. This study assessed the validity of a clinical sore throat score in 2 community emergency departments (EDs) and its impact on antibiotic prescribing. We also attempted to improve on this approach by using a rapid streptococcal antigen test. A total of 126 patients with new upper respiratory tract infections accompanied by sore throat were assessed by a physician. Pharyngeal swabs were obtained for a rapid test and throat culture, and information was gathered to determine the sore throat score. The sensitivity and specificity of the score approach were compared with usual physician care based on the rapid test results. Of the 126 cases of new upper respiratory infections with sore throat, physicians who followed their usual care routine, guided by the rapid test results, prescribed antibiotics for 46 patients. Of the 46 prescriptions, 18 were given to patients with culture-negative results for group A streptococcal (GAS) pharyngitis. Use of the sore throat score would not have reduced the number of prescriptions but would have missed only 1 patient with a positive culture result (p < 0.05). The rapid test was not as sensitive as throat culture. An explicit clinical score approach to the management of GAS pharyngitis is valid in a community ED setting and could improve the pattern of antibiotic prescribing. While the addition of a rapid streptococcal antigen test significantly decreased the sensitivity of detecting GAS infections, a combined approach consisting of the clinical score and throat culture for patients with negative results on the rapid test would decrease antibiotic prescribing and telephone follow-up without decreasing the sensitivity of detecting GAS infection.

PID27: DOES A DAY STILL MAKE A DIFFERENCE? A DECISION ANALYSIS OF ADULT STREPTOCOCCAL PHARYNGITIS

OBJECTIVES: Adults presenting with acute sore throats is one of the most common complaints encountered by primary care clinicians, yet the proper management of adult patients with pharyngitis is still somewhat controversial. This study proposes to identify the appropriate clinical management of adult pharyngitis using both cost-benefit analysis and cost-effectiveness analysis METHODS: Cost-Benefit Analysis and Cost-Effectiveness Analysis. Six management strategies were considered in these analyses: empiric treatment, performing a rapid test, obtaining a bacterial culture, empiric treatment with a confirmatory bacterial culture, or a combination of the rapid test with a bacterial culture of negative rapid tests. In addition, the study incorporates differing probabilities of streptococcal disease based upon on previously published symptomatically derived logistic regression scores. Using an internet-based survey, information is collected on undergraduate and graduate students' willingness-to-pay and time trade-off of presented health states. RESULTS: Preliminary results indicate that patients presenting with 3 or more indicative symptoms (3 days of fever> 39°C, tender anterior cervical nodes, enlarged tonsils with purulent exudates, and lack of cough) should be treated empirically. Those adult patients that complain of only two symptoms should be managed by a combination of a rapid diagnostic test with a bacterial culture on those rapid tests with negative results. CONCLUSIONS: This study presents findings that should provide clinicians with a better guide in the treatment of adult patients with pharyngitis. Performing normative analyses of currently accepted clinical management, the study employs adult's preferences as well as variation in severity of symptoms.

Assessing applicability of guidelines on management of pharyngitis in adults in general practice

Objectives – The GRAPH group evaluated whether guidelines for the treatment of pharyngitis in adults (>25 years of age) based on the use of Strep A (StA) rapid diagnostic tests (RDT) were applicable in general practice. Methods – A pragmatic “before-after” study was made to evaluate changes in practice after training. This was done over three periods: period I “before” and III “after” in which data on GPs' practice (about 100 general practitioners (GPs) from the Bourgogne and Rhone Alpes regions) was collected; period II when GPs underwent training including information on the conclusions of the consensus conference and training to use the Strep A RDT. Results – Data was collected on GPs' practice in around 900 cases of pharyngitis in each period (I et III) between October 1998 and March 1999. After just one training course, RDTs were performed in 93% of cases, with a positive rate of 20.2%. The overall use of antibiotics was reduced by 48.4% (42.6% in period III vs. 82.6% in period I, p<0.001). Furthermore, the analysis of antibiotic prescription profiles confirmed that the current reference treatment for pharyngitis (penicillin V for 10 days) was rarely applied (⩽5% of the total antibiotics prescriptions). In terms of economic impact, the mean total treatment cost for an episode of pharyngitis was respectively 1,011.70 F and 898.70 F in period I and III (cost difference = 113 F). Conclusions – The current guidelines (SPILF, AFSSAPS) on the management of pharyngitis are applicable in general practice and appropriately followed.

Évaluation de l'applicabilité du consensus sur la prise en charge de l'angine chez l'adulte

Objectives – The GRAPH group evaluated whether guidelines for the treatment of pharyngitis in adults (>25 years of age) based on the use of Strep A (StA) rapid diagnostic tests (RDT) were applicable in general practice. Methods – A pragmatic “before-after” study was made to evaluate changes in practice after training. This was done over three periods: period I “before” and III “after” in which data on GPs' practice (about 100 general practitioners (GPs) from the Bourgogne and Rhone Alpes regions) was collected; period II when GPs underwent training including information on the conclusions of the consensus conference and training to use the Strep A RDT. Results – Data was collected on GPs' practice in around 900 cases of pharyngitis in each period (I et III) between October 1998 and March 1999. After just one training course, RDTs were performed in 93% of cases, with a positive rate of 20.2%. The overall use of antibiotics was reduced by 48.4% (42.6% in period III vs. 82.6% in period I, p<0.001). Furthermore, the analysis of antibiotic prescription profiles confirmed that the current reference treatment for pharyngitis (penicillin V for 10 days) was rarely applied (⩽5% of the total antibiotics prescriptions). In terms of economic impact, the mean total treatment cost for an episode of pharyngitis was respectively 1,011.70 F and 898.70 F in period I and III (cost difference = 113 F). Conclusions – The current guidelines (SPILF, AFSSAPS) on the management of pharyngitis are applicable in general practice and appropriately followed.

Nonstreptococcal pharyngitis

Pharyngitis is the third most common illness diagnosed by pediatricians in the United States. Group A ß-hemolytic streptococci account for only approximately 30% of episodes of symptomatic pharyngitis. A broad list of other pathogens, including both bacteria and viruses, as well as Toxoplasma gondii and Candida species, are suggested frequently as the pathogens responsible for the remaining 70% of cases. This article reviews the evidence for a causative role of ß-hemolytic streptococci other than Streptococcus pyogenes and other bacteria and viruses in outbreaks and sporadic cases of pharyngitis. Recommendations for the diagnosis and management of pharyngitis caused by pathogens other than S pyogenes are offered.

Management issues in paediatric pharyngitis and otitis media

Pharyngitis and otitis media are among the most common infections of childhood. Both conditions are associated with a range of complications, lead to considerable morbidity and place a burden on healthcare systems. Antibiotics are the current mainstay of treatment for these infections, with β-lactams being the agents most commonly used. This review examines a range of issues in the management of pharyngitis and otitis media, particularly recent developments in antimicrobial therapy.

Practice variation in the management of pharyngitis: the importance of variability in patients' clinical characteristics and in physicians' responses to them.

The objective of this study was to assess whether geographic differences in antibiotic-prescribing rates for patients with pharyngitis could be explained by intersite differences in patients' clinical characteristics and in how physicians responded to these clinical cues when making decisions. As part of the initial phase of a prospective controlled trial to improve physicians' diagnostic ability, the authors enrolled cohorts of consecutive patients seen at staff-model--HMO student health services in Pennsylvania and Nebraska. Physicians' decisions whether to prescribe antibiotics for 310 consecutive patients presenting with pharyngitis to the former and 214 such patients presenting to the latter at the time of the initial visit were examined. There was a large discrepancy between the antibiotic-prescribing rates at the student health services in Pennsylvania, 106/310, 32.4%, and Nebraska, 156/214, 72.9%. The clinical variables significantly independently associated with treatment at both sites in a logistic regression model were fever, adjusted odds ratio = 2.1 (95% CI = 1.1, 3.8); exudates, 5.4 (2.8, 10); palatine petechiae, 6.5 (1.5, 28); rhinorrhea, 0.46, (0.25, 0.85); and high risk of complications, 3.8 (1.04, 14). There was a significant interaction between site and anterior cervical adenopathy, 5.5 (1.6, 19); and a borderline interaction between site and rhinorrhea, 2.4 (0.89, 6.7). Site was not a significant independent predictor of treatment, 1.8 (0.45, 6.6.). Practice variation was related to geographic differences in patients' clinical characteristics and in how physicians responded to these factors when prescribing antibiotics. How physicians weight patients' clinical characteristics when making decisions may be an important element of their "practice styles."

Etiology and Management of Pharyngitis and Pharyngotonsillitis in Children: A Current Review

Although viruses are the most common causes of childhood throat infections, interest in the etiology of these infections has primarily focused on whether an individual episode is caused by group A beta-hemolytic streptococcus (GABHS), particularly since the recent outbreaks of rheumatic fever in certain areas of the country. Penicillin remains the cornerstone of treatment in GABHS pharyngitis. Early treatment effects prompt clinical improvement and reduces the risk of transmission. Whether early treatment suppresses immunologic response and results in a higher recurrence rate than does delayed treatment is still unknown, but recent evidence suggests that it does not. The causes of persistent GABHS carriage, its clinical importance, and optimal methods of treatment are all still in question. When penicillin treatment does not eradicate carriage, other drugs may be efficacious. In children severely affected with recurrent throat infection, tonsillectomy is generally effective and is sometimes a desirable option.

A Resurgence of Acute Rheumatic Fever in a Mid-South Childrenʼs Hospital

A resurgence of acute rheumatic fever (ARF) has been reported in many areas of the United States in recent years. We retrospectively reviewed the medical records of inpatients with a new diagnosis of ARF from 1982 through 1988 at a children's hospital that serves a six-state referral area in the mid-South. Thirty patients were identified, 21 of whom were seen in 1987 (13) and 1988 (8). The rate of new cases of ARF per 1000 hospital discharges (0.7) was significantly greater for 1987 and 1988 than it was (0.15) from 1982 through 1986. Patients with recently diagnosed ARF were predominantly from nonurban areas, and polyarthritis was the most common recent major manifestation. Reasons for the resurgence of ARF in the US, including the mid-South, are unclear, but our experience serves to support recently published guidelines for the diagnosis and management of streptococcal pharyngitis in light of this resurgence of ARF.

Penicillin Tolerance and Erythromycin Resistance of Group A β-Hemolytic Streptococci in Hawaii and the Philippines

Penicillin remains the drug of choice for the treatment of streptococcal pharyngitis, with erythromycin as an alternative drug for individuals who cannot take penicillin. Two areas of concern in the management of streptococcal pharyngitis are (1) the prevalence of penicillin-tolerant group A beta-hemolytic streptococci reported in recent studies and (2) the high prevalence of erythromycin resistance in some geographic areas. We tested 305 isolates of group A beta-hemolytic streptococci from Hawaii and the Philippines for penicillin minimum inhibitory concentrations and minimum bactericidal concentrations and erythromycin minimum inhibitory concentrations. There was no evidence of penicillin resistance or tolerance. The prevalence of erythromycin-resistant and moderately susceptible isolates was 3.6% and 2.3%, respectively. There was a trend toward greater erythromycin resistance levels among Hawaiian isolates, but this was not statistically significant.