ID Pharyngitis =========== þ Journal Watch summary: Practice Guideline Comparisons for Strep Pharyngitis Recommendations for the management of group A streptococcus (GAS) pharyngitis vary from throat cultures or in-office rapid-antigen tests (RATs) for all patients with sore throats to empirical treatment based on clinical scoring systems (such as the modified Centor score [see below{dagger}]). Researchers at a Canadian family practice clinic performed throat cultures and RATs on 787 children and adults who had modified Centor scores of 2 or higher. Six management strategies were evaluated: * (1) Obtain cultures on all patients. Treat culture-positive patients. * (2) Perform RAT in all patients. Treat RAT-positive children and obtain cultures in RAT-negative children; treat only RAT-positive adults (no cultures in adults). * (3) Manage children as in strategy #2. Among adults with Centor scores of 2 or 3, perform RATs and treat RAT-positive patients; among adults with Centor scores of 4, treat empirically. * (4) Manage children as in strategy #2. Empirically treat adults with Centor scores of 3 or higher. * (5) Obtain cultures for all patients with Centor scores of 2 or 3, and treat culture-positive patients; empirically treat patients with Centor scores of 4 or higher. * (6) Perform RATs on all patients. Treat only RAT-positive patients (no cultures in any group). The prevalence of positive throat cultures was 29% (34% in children; 22% in adults). Overall, all strategies except #6 had sensitivities higher than 90% for identifying GAS pharyngitis, and specificities were higher than 93% in all strategies except #4. Unnecessary antibiotic use in children ranged from 0.7% in most strategies to 6.4% in strategy #5; unnecessary antibiotic use in adults ranged from 0.6% in most strategies to 44% in strategy #4. Comment: Among adults, strategy #1 is most effective but also most cumbersome. Strategy #5 is probably the most practical and has the optimal combination of sensitivity, specificity, and low rate of unnecessary antibiotic use. Among children, all strategies have high sensitivity and specificity; #5 has the highest rate of unnecessary antibiotic use (but this was still only 6%). As an easily remembered and practical approach, many physicians might choose #5 for both children and adults, although #1, #2, or #3 would be effective for children as well. - Thomas L. Schwenk, MD {dagger}Modified Centor Scoring System involves the following criteria: temperature, >38øC: 1 point; absence of cough: 1 point; swollen, tender anterior cervical nodes: 1 point; tonsillar swelling or exudates: 1 point; age 3-14 years: 1 point; age 15-44 years: 0 points; age >=45 years: -1 point. Published in Journal Watch April 30, 2004 Source McIsaac WJ et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004 Apr 7; 291:1587-95. þ Empiric Treatment of Acute Pharyngitis [Green SM. Acute pharyngitis: The case for empiric antimicrobial therapy. Ann Emerg Med 1995;3(1):404-6.] þ Pertussis þ Peritonsillar Abscess þ Strep Throat þ Pharyngitis Etiology - Clinical findings tell you nothing about whether it is strep or not. - Strep is almost nonexistent in kids under 3, and rare even in older kids. In adults it is more common. [Putto A. Febrile exudative tonsillitis: viral or streptococcal. Pediatrics 1987 80(1)] - Chlamydia and Ureaplasma are the most common (21%, 18%) causes of pharyngitis in adults (strep is 11% and mono 2%) [Komaroff AL. Serologic evidence of chlamydial and mycoplasmal pharyngitis in adults. Science 1983 222:927] - Study of 106 adults: beta strep 23%, Mycoplasma 9%, Chlamydia TWAR 8%, viral 25%, two pathogens 3%, no findings 31% [Annals Int Med 1989] þ Pharyngitis Treatment - An article in American Family Physician, , recommends patients with a greater than 50% liklihood of streptoccal pharyngitis should be treated empirically and does not recommend any testing. A greater than 50% liklihood of strep pharyngitis was defined as a patient who presented with: 1) fever, 2) cervical adenopathy, 3) erythematous pharynx with or without exudate and no cough or coryza. The chance of strep pharyngitis is also >50% if there is a positive history in other household members. Jeff Myers, NREMTP MSI UNECOM myersj@rpi.edu [Perkins A. An approach to diagnosing the acute sore throat. AFP January 1997, 55(1):131-138] - Erythro vs. placebo for pharyngitis: more side effects from erythro but very effective [J ID 1985 ] - PCN if rapid strep +; erythro if PCN allergic or rapid strep -; for refractory cases, clinda or rifampin. þ Steroids for Severe Pharyngitis þ Effect of antibiotics on pain of pharyngitis: - "Studies have indicated that antibiotics do, in fact, hasten the relief of pain in a strep throat. The archaic practice of doing a culture and then waiting for 24 to 48 hours to begin antibiotics because 'the course is similar with or eithout treatment' has been proven to be erroneous." Roberts JE. Symptomatic treatment for acute pharyngitis. Emerg Med News 1996 18(1):6-7.