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Journal of General Internal Medicine Jan 2007Despite numerous controlled trials, clinical practice guidelines and cost-effective analyses, controversy persists regarding the appropriate management strategy for... (Review)
Review
Despite numerous controlled trials, clinical practice guidelines and cost-effective analyses, controversy persists regarding the appropriate management strategy for adult pharyngitis. In this perspective, we explore this controversy by comparing two competing clinical guidelines. Although the guidelines appear to make widely diverging recommendations, we show that the controversy centers on only a small proportion of patients: those presenting with severe pharyngitis. We examine recently published data to illustrate that this seemingly simple problem of strep throat remains a philosophical issue: should we give primacy to relieving acute time-limited symptoms, or should we emphasize the potential societal risk of antibiotic resistance? We accept potentially over treating a minority of adult pharyngitis patients with the most severe presentations to reduce suffering in an approximately equal number of patients who will have false negative test results if the test-and-treat strategy were used.
Topics: Anti-Bacterial Agents; Antigens, Bacterial; Drug Resistance, Bacterial; Humans; Pharyngitis; Practice Guidelines as Topic; Reagent Kits, Diagnostic; Severity of Illness Index
PubMed: 17351852
DOI: 10.1007/s11606-006-0020-4 -
BMC Pediatrics Feb 2018Group A streptococcus (GAS) is the most common bacterial etiology of pharyngitis but is difficult to distinguish clinically from viral pharyngitis. There are benefits to...
BACKGROUND
Group A streptococcus (GAS) is the most common bacterial etiology of pharyngitis but is difficult to distinguish clinically from viral pharyngitis. There are benefits to early antibacterial treatment of GAS pharyngitis, but administering antibiotics to children with viral pharyngitis is ineffective and costly. We evaluated adherence to guidelines that were developed to help clinicians distinguish between viral and GAS pharyngitis and guide management.
METHODS
Retrospective cohort study of patients ages 3-18 who had a rapid streptococcal test and/or throat culture performed in an outpatient setting. We collected data on documentation of components of the McIsaac score and classified tests as indicated if the score was ≥2. Based on McIsaac score and GAS test results, we determined whether each antibiotic course prescribed was indicated according to the Infectious Diseases Society of America guideline.
RESULTS
Among 291 eligible children, 87 (30%) had all five components of the McIsaac score documented. There was sufficient data to classify the score as either < 2 or ≥2 in 234 (80%); among these, 96% of tests were indicated. Twenty-nine patients (10%) were prescribed antibiotics. Eight (28%) of these prescriptions were not indicated according to guidelines.
CONCLUSIONS
The majority of GAS tests in children with pharyngitis are indicated, although providers do not regularly document all elements of a validated pharyngitis scoring tool. Over one quarter of children prescribed antibiotics for pharyngitis did not require antibiotics according to guidelines. There remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings.
Topics: Adolescent; Anti-Bacterial Agents; Child; Child, Preschool; Diagnosis, Differential; Female; Guideline Adherence; Humans; Male; Pharyngitis; Practice Guidelines as Topic; Retrospective Studies; Streptococcal Infections; Virus Diseases
PubMed: 29426305
DOI: 10.1186/s12887-018-0988-z -
PloS One 2023Streptoccocal A (Strep A, GAS) infections in Australia are responsible for significant morbidity and mortality through both invasive (iGAS) and post-streptococcal...
BACKGROUND
Streptoccocal A (Strep A, GAS) infections in Australia are responsible for significant morbidity and mortality through both invasive (iGAS) and post-streptococcal (postGAS) diseases as well as preceding superficial (sGAS) skin and throat infection. The burden of iGAS and postGAS are addressed in some jurisdictions by mandatory notification systems; in contrast, the burden of preceding sGAS has no reporting structure, and is less well defined. This review provides valuable, contemporaneous evidence on the epidemiology of sGAS presentations in Australia, informing preventative health projects such as a Streptococcal A vaccine and standardisation of primary care notification.
METHODS AND FINDINGS
MEDLINE, Scopus, EMBASE, Web of Science, Global Health, Cochrane, CINAHL databases and the grey literature were searched for studies from an Australian setting relating to the epidemiology of sGAS infections between 1970 and 2020 inclusive. Extracted data were pooled for relevant population and subgroup analysis. From 5157 titles in the databases combined with 186 grey literature reports and following removal of duplicates, 4889 articles underwent preliminary title screening. The abstract of 519 articles were reviewed with 162 articles identified for full text review, and 38 articles identified for inclusion. The majority of data was collected for impetigo in Aboriginal and Torres Strait Islander populations, remote communities, and in the Northern Territory, Australia. A paucity of data was noted for Aboriginal and Torres Strait Islander people living in urban centres or with pharyngitis. Prevalence estimates have not significantly changed over time. Community estimates of impetigo point prevalence ranged from 5.5-66.1%, with a pooled prevalence of 27.9% [95% CI: 20.0-36.5%]. All studies excepting one included >80% Aboriginal and Torres Strait Islander people and all excepting two were in remote or very remote settings. Observed prevalence of impetigo as diagnosed in healthcare encounters was lower, with a pooled estimate of 10.6% [95% CI: 3.1-21.8%], and a range of 0.1-50.0%. Community prevalence estimates for pharyngitis ranged from 0.2-39.4%, with a pooled estimate of 12.5% [95% CI: 3.5-25.9%], higher than the prevalence of pharyngitis in healthcare encounters; ranging from 1.0-5.0%, and a pooled estimate of 2.0% [95% CI: 1.3-2.8%]. The review was limited by heterogeneity in study design and lack of comparator studies for some populations.
CONCLUSIONS
Superficial Streptococcal A infections contribute to an inequitable burden of disease in Australia and persists despite public health interventions. The burden in community studies is generally higher than in health-services settings, suggesting under-recognition, possible normalisation and missed opportunities for treatment to prevent postGAS. The available, reported epidemiology is heterogeneous. Standardised nation-wide notification for sGAS disease surveillance must be considered in combination with the development of a Communicable Diseases Network of Australia (CDNA) Series of National Guideline (SoNG), to accurately define and address disease burden across populations in Australia.
TRIAL REGISTRATION
This review is registered with PROSPERO. Registration number: CRD42019140440.
Topics: Humans; Australian Aboriginal and Torres Strait Islander Peoples; Health Services, Indigenous; Impetigo; Northern Territory; Pharyngitis; Streptococcus
PubMed: 38033025
DOI: 10.1371/journal.pone.0288016 -
PloS One 2022Acute pharyngitis (AP) is a common reason for private primary care consultations, thus providing an avenue for widespread antibiotic intake among the community. However,...
Respiratory microorganisms in acute pharyngitis patients: Identification, antibiotic prescription patterns and appropriateness, and antibiotic resistance in private primary care, central Malaysia.
Acute pharyngitis (AP) is a common reason for private primary care consultations, thus providing an avenue for widespread antibiotic intake among the community. However, there is limited data on the antibiotic prescription appropriateness and resistance information in the Malaysian private primary care setting, therefore, this study aimed to investigate the prevalence of isolated viruses and bacteria, antibiotic resistance patterns, antibiotic prescription patterns and appropriateness by general practitioners (GPs) and factors affecting antibiotic resistance and antibiotic prescription patterns. To investigate, a cross-sectional study was conducted among 205 patients presenting with AP symptoms at private primary care clinics in central Malaysia from 3rd January 2016 to 30th November 2016. Throat swabs were collected from 205 AP patients for two purposes: (i) the detection of four common respiratory viruses associated with AP via reverse-transcription real-time PCR (qRT-PCR); and (ii) bacterial identification using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Bacterial isolates were then subjected to antibiotic susceptibility screening and McIsaac scoring was calculated post-prescription based on GP selection of criteria. Generalized estimating equations analysis with multiple logistic regression was conducted to identify factors associated with presence of virus and antibiotic prescription. The results showed that 95.1% (195/205) of patients had at least one of the four viruses, with rhinovirus (88.5%) being the most prevalent, followed by adenovirus (74.9%), influenza A virus (4.6%) and enterovirus (2.1%). A total of 862 non-repetitive colonies were isolated from the culture of throat swabs from 205 patients who were positive for bacteria. From a total of 22 genera, Streptococcus constitutes the most prevalent bacteria genus (40.9%), followed by Neisseria (20%), Rothia (13.0%), Staphylococcus (11%) and Klebsiella (4.9%). Only 5 patients carried group A beta-hemolytic streptococci (GABHS). We also report the presence of vancomycin-resistant S. aureus or VRSA (n = 9, 10.1%) among which one isolate is a multidrug-resistant methicillin-resistant S. aureus (MDR-MRSA), while 54.1% (n = 111) were found to carry at least one antibiotic-resistant bacteria species. Application of the McIsaac scoring system indicated that 87.8% (n = 180) of patients should not be prescribed antibiotics as the majority of AP patients in this study had viral pharyngitis. The antibiotic prescription appropriateness by applying post-prescription McIsaac scoring was able to rule out GABHS pharyngitis in this sample with a GABHS culture-positive sensitivity of 40% (n = 2/5) and specificity of 90% (180/200). In conclusion, antibiotic-resistant throat isolates and over-prescription of antibiotics were observed and McIsaac scoring system is effective in guiding GPs to determine occurrences of viral pharyngitis to reduce unnecessary antibiotic prescription.
Topics: Humans; Anti-Bacterial Agents; Cross-Sectional Studies; Malaysia; Methicillin-Resistant Staphylococcus aureus; Pharyngitis; Drug Resistance, Microbial; Prescriptions; Streptococcus; Bacteria; Viruses; Primary Health Care
PubMed: 36395327
DOI: 10.1371/journal.pone.0277802 -
PloS One 2020Group A streptococcal (GAS) pharyngitis has traditionally been considered the sole precursor of acute rheumatic fever (ARF). Evidence from Australia, however, suggests... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Group A streptococcal (GAS) pharyngitis has traditionally been considered the sole precursor of acute rheumatic fever (ARF). Evidence from Australia, however, suggests that GAS skin infections may contribute to the pathogenesis of ARF. A missing piece of evidence is the incidence of sore throat and GAS pharyngitis in this setting. We conducted a systematic review and meta-analysis of the incidence of sore throat and GAS pharyngitis in all children at risk of developing ARF.
METHODS
Databases were systematically searched for studies reporting on the incidence of pharyngitis among children from low to upper-middle income countries, and Indigenous children living in high-income countries. Studies were subjected to data extraction by two independent reviewers. Following an assessment of the methodological quality of the studies, we extracted incidence rates (IRs) and conducted a meta-analysis. This systematic review is registered on PROSPERO (CRD42019113019).
RESULTS
From 607 titles identified by the search, 11 articles met the predetermined inclusion criteria; ten studies reported IRs while for the remaining study, the incidence was calculated. The pooled incidence estimated for sore throat was 82.5 per 100 child-years (95% confidence interval [CI], 6.5 to 1044.4 per 100 child-years, I2 = 100%) and GAS pharyngitis was 10.8 per 100 child-years (95% CI, 2.3 to 50.0 per 100 child-years, I2 = 99.9%).
CONCLUSIONS
The pooled IRs for sore throat in children at risk of developing ARF were higher than rates reported in developed nations (32.70-40 per 100 child-years) and similar for GAS pharyngitis (12.8-14 per 100 years). The limited Australian data lend support to the need for further studies to inform the role of GAS pharyngitis in the development of ARF in Australian Indigenous children, so as to inform local primary prevention strategies for ARF and Rheumatic Heart Disease (RHD).
Topics: Adolescent; Child; Child, Preschool; Female; Humans; Incidence; Infant; Male; Pharyngitis; Rheumatic Fever
PubMed: 33206687
DOI: 10.1371/journal.pone.0242107 -
Lab on a Chip Sep 2022is a major human-specific bacterial pathogen and a common cause of a wide range of symptoms from mild infection such as pharyngitis (commonly called strep throat) to...
is a major human-specific bacterial pathogen and a common cause of a wide range of symptoms from mild infection such as pharyngitis (commonly called strep throat) to life-threatening invasive infection and post-infectious sequelae. Traditional methods for diagnosis include collecting a sample using a pharyngeal swab, which can cause discomfort and even discourage adults and children from seeking proper testing and treatment in the clinic. Saliva samples are an alternative to pharyngeal swabs. To improve the testing experience for strep throat, we developed a novel lollipop-inspired sampling platform (called CandyCollect) to capture bacteria in saliva. The device can be used in clinics or in the home and shipped back to a lab for analysis, integrating with telemedicine. CandyCollect is designed to capture bacteria on an oxygen plasma treated polystyrene surface embedded with flavoring substances to enhance the experience for children and inform the required time to complete the sampling process. In addition, the open channel structure prevents the tongue from scraping and removing the captured bacteria. The flavoring substances did not affect bacterial capture and the device has a shelf life of at least 2 months (with experiments ongoing to extend the shelf life). We performed a usability study with 17 participants who provided feedback on the device design and the dissolving time of the candy. This technology and advanced processing techniques, including polymerase chain reaction (PCR), will enable user-friendly and effective diagnosis of streptococcal pharyngitis.
Topics: Adult; Child; Humans; Pharyngitis; Polymerase Chain Reaction; Saliva; Streptococcal Infections; Streptococcus pyogenes
PubMed: 35983761
DOI: 10.1039/d1lc01132d -
Semergen Oct 2015Acute pharyngitis in adults is one of the most common infectious diseases seen in general practitioners' consultations. Viral aetiology is the most common. Among... (Review)
Review
Acute pharyngitis in adults is one of the most common infectious diseases seen in general practitioners' consultations. Viral aetiology is the most common. Among bacterial causes, the main agent is Streptococcus pyogenes or group A β-haemolytic streptococcus (GABHS), which causes 5%-30% of the episodes. In the diagnostic process, clinical assessment scales can help clinicians to better predict suspected bacterial aetiology by selecting patients who should undergo a rapid antigen detection test. If these techniques are not performed, an overdiagnosis of streptococcal pharyngitis often occurs, resulting in unnecessary prescriptions of antibiotics, most of which are broad spectrum. Consequently, management algorithms that include the use of predictive clinical rules and rapid tests have been set up. The aim of the treatment is speeding up symptom resolution, reducing the contagious time span and preventing local suppurative and non-suppurative complications. Penicillin and amoxicillin are the antibiotics of choice for the treatment of pharyngitis. The association of amoxicillin and clavulanate is not indicated as the initial treatment of acute infection. Neither are macrolides indicated as first-line therapy; they should be reserved for patients allergic to penicillin. The appropriate diagnosis of bacterial pharyngitis and proper use of antibiotics based on the scientific evidence available are crucial. Using management algorithms can be helpful in identifying and screening the cases that do not require antibiotic therapy.
Topics: Acute Disease; Adult; Algorithms; Anti-Bacterial Agents; Humans; Pharyngitis; Streptococcal Infections; Streptococcus pyogenes
PubMed: 26004567
DOI: 10.1016/j.semerg.2014.12.013 -
BMC Infectious Diseases Feb 2019Clinical guidelines for the diagnosis of group A streptococcal (GAS) pharyngitis recommend the use of a rapid antigen detection test (RADT) and/or bacterial culture....
BACKGROUND
Clinical guidelines for the diagnosis of group A streptococcal (GAS) pharyngitis recommend the use of a rapid antigen detection test (RADT) and/or bacterial culture. This study evaluated the overall diagnosis and treatment of acute pharyngitis in the United States, including predictors of test type and antibiotic prescription.
METHODS
A retrospective analysis of pharyngitis events from 2011 through 2015 was conducted using the MarketScan commercial/Medicare databases. A pharyngitis event was defined as occurring within 2 weeks from the index visit. Patient and provider characteristics were examined across 5 testing categories: RADT, RADT plus culture, other tests, nucleic acid amplification testing (NAAT), and no test. Multivariate models were used to identify significant predictors of NAAT use and antibiotic prescription.
RESULTS
A total of 18.8 million acute pharyngitis events were identified in 11.6 million patients. Roughly two-thirds of events (68.2%) occurred once, and roughly a third of patients (29.1%) required additional follow-up, but hospitalization was rare (0.3%). Across all events, 43% were diagnosed by RADT, while 20% were diagnosed by RADT plus culture. The proportion of events diagnosed by NAAT increased 3.5-fold from 2011 to 2015 (0.06% vs 0.27%). Antibiotic use was frequent (49.3%), less often in combination with RADT plus culture (31.2%) or NAAT alone (34.5%) but significantly more often with RADT alone (53.4%) or no test (57.1%). Pediatricians were significantly less likely than other providers to prescribe antibiotics in their patients, regardless of patient age (p < 0.0001).
CONCLUSIONS
Antibiotic use for sore throat remains common, with many clinicians not following current guidelines for diagnosis of GAS pharyngitis. Diagnosis of GAS pharyngitis using RADT plus culture or NAAT alone was associated with lower use of antibiotics. Diagnostic testing can help lower the incidence of inappropriate antibiotic use, and inclusion of NAAT in the clinical guidelines for GAS pharyngitis warrants consideration.
Topics: Adolescent; Adult; Anti-Bacterial Agents; Child; Drug Prescriptions; Female; Humans; Immunologic Tests; Male; Nucleic Acid Amplification Techniques; Pharyngitis; Practice Guidelines as Topic; Retrospective Studies; Streptococcal Infections; Streptococcus pyogenes; United States
PubMed: 30808305
DOI: 10.1186/s12879-019-3835-4 -
Italian Journal of Pediatrics Jan 2011Streptococcal pharyngitis is a very common pathology in paediatric age all over the world. Nevertheless there isn't a joint agreement on the management of this... (Review)
Review
Streptococcal pharyngitis is a very common pathology in paediatric age all over the world. Nevertheless there isn't a joint agreement on the management of this condition. Some authors recommend to perform a microbiological investigation in suspected bacterial cases in order to treat the confirmed cases with antibiotics so to prevent suppurative complications and acute rheumatic fever. Differently, other authors consider pharyngitis, even streptococcal one, a benign, self-limiting disease. Consequently they wouldn't routinely perform microbiological tests and, pointing to a judicious use of antibiotics, they would reserve antimicrobial treatment to well-selected cases. It has been calculated that the number of patients needed to treat to prevent one complication after upper respiratory tract infections (including sore throat), was over 4000. Even the use of the Centor score, in order to evaluate the risk of streptococcal infection, is under debate and the interpretation of the test results may vary considerably. Penicillin is considered all over the world as first line treatment, but oral amoxicillin is also accepted and, due to its better palatability, can be a suitable option. Macrolides should be reserved to the rare cases of proved allergy to β-lactams. Cephalosporins can be used in patients allergic to penicillin (with the exception of type I hypersensibility) and have been also proposed to treat the relapses.
Topics: Acute Disease; Anti-Bacterial Agents; Bacteriological Techniques; Child; Global Health; Humans; Incidence; Pharyngitis; Practice Guidelines as Topic; Prognosis
PubMed: 21281502
DOI: 10.1186/1824-7288-37-10 -
International Journal of Medical... 2022Post-anaesthetic sore throat (PAST) is a well-recognized consequence of tracheal intubation; however, quantitative morphometric measurements remain challenging. This...
Post-anaesthetic sore throat (PAST) is a well-recognized consequence of tracheal intubation; however, quantitative morphometric measurements remain challenging. This study aimed to introduce a special laser projection device that can facilitate computer-assisted, digitalized analysis and provide important information on laryngeal mucosa change, pre and post-surgery under general anesthesia with intubation. The laryngeal images were captured and divided into the control group and the intubation group. Image processing techniques were used to quantify the post-extubation laryngeal variation, with its distinct color space and texture features. Meanwhile, the maximum length of the vocal fold, vocal width at the midpoint, and maximum cross-sectional area of the glottic space were determined and calculated. These parameters were analyzed and compared pre and post-surgery. A total of 69 subjects were enrolled in this study, comprising 32 subjects in the healthy group and 37 subjects in the intubation group. The color space and texture analysis with contrast and correlation profiles all shows trend toward higher measures in the intubation group than in the healthy group, with statistical significance and outstanding discrimination ability, especially in the interarytenoid region. The incidence of PAST was approximately 46% (17 patients). The gender difference, type of surgery, and the fixation position of the tube were not significantly related to the PAST occurrence. All the eigenvalues showed significant differences pre and post-surgery in the interarytenoid region and a significant trend toward red and increased contrast texture profiles was revealed. Furthermore, the glottic area showed a significant decrease of 25.29%, while the vocal width showed a significant increase post extubation. Our equipment and processing can measure subtle laryngeal changes that would allow a clinician to diagnose postoperative laryngeal inflammation in a simpler and less invasive way. The trend toward red, the increased contrast texture and vocal width, and the reduced glottic space were all compatible with post-intubation inflammatory response, especially in the interarytenoid region. This is important to know so that one can take appropriate steps to alleviate PAST in the future.
Topics: Adult; Anesthesia, General; Humans; Intubation, Intratracheal; Larynx; Pharyngitis; Postoperative Period
PubMed: 35370474
DOI: 10.7150/ijms.69425