The diagnosis of strep throat in adults in the emergency room

Application of a simple point-of-care test to reduce UK healthcare costs and adverse events in outpatient acute respiratory infections

Background: Acute respiratory infection (ARI) accounts for over two-thirds of total antibiotic prescriptions although most are caused by viruses that do not benefit from antibiotics. Most antibiotics are prescribed in the outpatients setting. Antibiotic overuse leads to antibiotic-related adverse events (AEs), inclusive of secondary infections, resistance, and increased costs. Point-of-care tests (POCT) may reduce unnecessary antibiotics. A cost analysis was performed to assess diagnostic POCT options to identify patients with an ARI that may benefit from antibiotics in a United Kingdom (UK) outpatient setting.Methods: Healthcare savings were estimated using a budget impact analysis based on UK National Institute for Health and Care Excellence (NICE) data and direct costs (antibiotics, AEs, POCTs) derived from published literature. Otitis media, sinusitis, pharyngitis and bronchitis were considered the most common ARIs. Antibiotic-related AE costs were calculated using re-consultation costs for anaphylaxis, Stevens-Johnson syndrome, allergies/diarrhea/nausea, C. difficile infection (CDI). Potential cost-savings from POCTs was assessed by evaluating NICE guideline-referenced POCTs (CRP, FebriDx, Sarasota, FL) as well as a target product profile (TPP).Results: Fifty-percent (7,718,283) of ARI consultations resulted in antibiotics while guideline-based prescribing suggest appropriate antibiotic prescriptions are warranted 9% (1,444,877) of ARI consultations. Direct antibiotic costs for actual ARI consultations associated with antibiotics was £24,003,866 vs. £4,493,568 for guideline-based, "appropriate" antibiotic prescriptions. Antibiotic-related AEs and re-consultations for actual vs. appropriate prescribing totaled £302,496,486 vs. £63,854,269. ARI prescribing plus AE costs totaled £326,729,943 annually without the use of delayed prescribing practices or POCT while the addition of delayed prescribing plus POCT totaled £60,114,564-£78,148,933 depending on the POCT.Conclusions: Adding POCT to outpatient triage of ARI can reduce unnecessary antibiotics and antibiotic-related AEs, resulting in substantial cost savings. Further, near patient diagnostic testing can benefit health systems and patients by avoiding exposure to unnecessary drugs, side effects and antibiotic resistant pathogens.Key points for decision makersMany patients are unnecessarily treated with antibiotics for respiratory infections.Antibiotic misuse leads to unnecessary adverse events, secondary infections, re-consultations, antimicrobial resistance and increased costs.Point-of-care diagnostic tests used to guide antibiotic prescriptions will avoid unnecessary adverse health effects and expenses.

Are Symptoms Sufficient in the Decision to Start Antibiotics in Tonsillopharyngitis?

OBJECTIVES

Unnecessary use of antibiotics is one of the causes of antibiotic resistance. Rapid Antigen Test (RAT) is recommended to prevent unnecessary use of antibiotics by providing bacteria/virus isolation in patients with tonsillopharyngitis. However, in patients with typical symptoms, false-negative test results may lead to doubt in doctors. In this study, we aimed to evaluate the relationship between patients' symptoms and RAT results.

METHODS

In this study, we chose the patients that referred to the University of Health Sciences (SBÜ) Şişli Hamidiye Etfal Training and Research Hospital Family Medicine Polyclinics and got a diagnosis of tonsillopharyngitis with RAT. This study was conducted by a retrospective file scanning method. We examined the age, sex, symptoms, RAT results and throat culture results of the patients. SPSS 15.0 for Windows program was used for the statistical analysis. The level of statistical significance was accepted as p<0.05.

RESULTS

In this study, the RAT of 265 patients and the throat culture of 141 patients were examined. We found RAT positivity as 28.7%, Group A Beta Hemolytic Streptococcus (AGBHS) detection rate in throat culture was 22.5%, and the antibiotic prescription rate was 37%. There were 32 patients with AGBHS positivity in throat culture. Twenty-seven of them got RAT positivity, too. When symptoms and RAT positivity were examined, there was no significant relationship between RAT positivity and fever higher than 38 oC, but RAT was more often positive in patients with a fever higher than 38 oC. On the other hand, there is a statistically significant relationship between RAT positivity and the presence of tonsillar exudate (p=0.000). When the relationship between symptoms and RAT according to age groups was examined, the presence of LAP and tonsillitis were significant (p=0.000; p=0.001). In the age group of 18 years and over, the presence of tonsillar exudates was significant (p=0.001).

CONCLUSION

In our study, tonsillar exudate was a common symptom in both age groups of <18, and ≥18 years of age; at the same time, there is a statistically significant relation with RAT. Tonsillar exudates are not seen only in bacterial infections but also in viral infections. Thus, we think that antibiotics should not be started based on symptoms, and RAT should be used effectively.

Long-term impact of an intervention on rapid antigen detection tests in acute pharyngitis

Objective

This study was aimed at evaluating the appropriateness of use and interpretation of rapid antigen detection testing (RADT) and antibiotic prescribing for acute pharyngitis six years after a multifaceted intervention.

Design

Before-and-after audit-based study.

Location

Primary care centres in eight autonomous Communities.

Participants

General practitioners (GP) who had participated in the HAPPY AUDIT intervention study in 2008 and 2009 were invited to participate in a third audit-based study six years later (2015).

Method

RADTs were provided to the participating practices and the GPs were requested to consecutively register all adults with acute pharyngitis. A registration form specifically designed for this study was used.

Results

A total of 121 GPs out of the 210 who participated in the first two audits agreed to participate in the third audit (57.6%). They registered 3394 episodes of pharyngitis in the three registrations. RADTs were used in 51.7% of all the cases immediately after the intervention, and in 49.4% six years later. Antibiotics were prescribed in 21.3% and 36.1%, respectively (P < .001), mainly when tonsillar exudates were present, and in 5.3% and 19.2% of those with negative RADT results (P< .001). On adjustment for covariables, compared to the antibiotic prescription observed just after the intervention, significantly more antibiotics were prescribed six years later (odds ratio: 2.24, 95% confidence interval: 1.73–2.89).

Conclusions

This study shows that that the long-term impact of a multifaceted intervention, focusing on the use and interpretation of RADT in patients with acute pharyngitis, is reducing.

Group A Streptococcus Testing in Pediatrics: the Move to Point-of-Care Molecular Testing

Each year, there are an estimated 11 million visits to ambulatory care centers for pharyngitis in children between the ages of 3 and 18 years. While there are many causes of pediatric pharyngitis, group A streptococcal pharyngitis represents 15 to 30% of infections and is the only cause for which treatment is recommended. Unfortunately, clinical suspicion is insufficient for the accurate diagnosis of group A streptococcal pharyngitis, and laboratory testing for confirmation of Streptococcus pyogenes infection is required to prevent complications of infection. Traditionally, throat swabs are inoculated onto agar plates for isolation of the large-zone beta-hemolytic streptococcus. However, traditional culture methods present a potential delay in treatment due to turnaround times of 18 to 48 h. In order to improve turnaround times and enhance antimicrobial stewardship, multiple point-of-care assays have been developed. This review describes current point-of-care testing for group A streptococcal pharyngitis, including rapid antigen detection tests and more recent molecular methods. Additional attention is given to the diagnostic considerations when choosing a method for group A streptococcal point-of-care testing, implementation of molecular group A streptococcal testing, and the institutional cost of immunoassays compared to those of newer molecular methods.

Infectious Disease and Primary Care Research-What English General Practitioners Say They Need

BACKGROUND

Infections are one of the most common reasons for patients attending primary care. Antimicrobial resistance (AMR) is perhaps one of the biggest threats to modern medicine; data show that 81% of antibiotics in the UK are prescribed in primary care.

AIM

To identify where the perceived gaps in knowledge, skills, guidance and research around infections and antibiotic use lie from the general practitioner (GP) viewpoint.

DESIGN AND SETTING

An online questionnaire survey.

METHOD

The survey, based on questions asked of Royal College of General Practitioners (RCGP) members in 1999, and covering letter were electronically sent to GPs between May and August 2017 via various primary care dissemination routes.

RESULTS

Four hundred and twenty-eight GPs responded. Suspected Infection in the elderly, recurrent urinary tract infection (UTI), surveillance of AMR in the community, leg ulcers, persistent cough and cellulitis all fell into the top six conditions ranked in order of importance that require further research, evidence and guidance. Acute sore throat, otitis media and sinusitis were of lower importance than in 1999.

CONCLUSION

This survey will help the NHS, the UK National Institute for Health and Care Excellence (NICE) and researchers to prioritise for the development of guidance and research for chronic conditions highlighted for which there is little evidence base for diagnostic and management guidelines in primary care. In contrast, 20 years of investment into research, guidance and resources for acute respiratory infections have successfully reduced these as priority areas for GPs.

Neutrophil gelatinase associated lipocalin a biomarker for bacterial-induced pharyngeal infection-A pilot study

OBJECTIVES

Neutrophil gelatinase associated lipocalin (NGAL) is secreted from activated neutrophil granulocytes and is considered an acute phase protein. The aim of this pilot study was to determine whether the NGAL concentration in saliva increases in response to a bacterial throat infection and identify pitfalls, which shall be taken into account in a protocol in a larger hypothesis testing study.

METHODS

Saliva samples for measurement of NGAL concentration where obtained from cases with an acute throat infection (n = 21) and controls (n = 24). Among cases, plasma NGAL, plasma CRP, and whole blood leukocytes, were measured as well.

RESULTS

There was no significant difference in NGAL saliva concentration between cases and controls overall (p = .31). For both cases and controls, the saliva NGAL concentration decreased significantly after cleansing the mouth with tap water (cases p = .01; controls p = .01). Among cases, a significant positive correlation between saliva NGAL concentrations before mouth cleansing and plasma CRP concentrations (p = .001) was observed. Blood neutrophil granulocyte count presented a nonsignificant positive correlation to saliva NGAL (p = .07).

CONCLUSION

We could not demonstrate a simple association between the salivary NGAL concentration and pharyngeal bacterial infection. Furthermore, the salivary NGAL concentrations were higher among some controls than cases, suggesting that cofounders for example, periodontitis, uneven salivary dilution level, or other exogenous factors affect salivary NGAL content.

Fulminating deep tissue space infection with Streptococcus constellatus presenting initially as a sore throat

Management of sore throat requires robust decision-making to balance successfully the conflicting risks of unnecessary antibiotic use against those of untreated bacterial infection. We present a case of fulminant sepsis caused by Streptococcus constellatus, presenting as a sore throat, initially managed conservatively. Despite subsequent appropriate anti-microbial therapy and surgical drainage, contiguous spread ultimately involved the deep neck spaces, mediastinum and thoracic wall, and was complicated by severe aspiration pneumonia, pharyngocutaneous and bronchopleural fistulation. The complexity and widespread extent of the infected spaces, in conjunction with the catabolic response to sepsis, created a life-threatening situation. Surgical closure of the pharyngeal defect, using a pectoralis-major pedicle flap, was successfully undertaken to ensure source control of the infection and heralded a complete recovery. We describe our management of this case, discuss the current approach to the management of patients presenting with a sore throat, and review the literature on S. constellatus infections.

Comparison of Centor and McIsaac scores in primary care: a meta-analysis over multiple thresholds

Background

Centor and McIsaac scores are both used to diagnose group A beta-haemolytic streptococcus (GABHS) infection, but have not been compared through meta-analysis.

Aim

To compare the performance of Centor and McIsaac scores at diagnosing patients with GABHS presenting to primary care with pharyngitis.

Design and setting

A meta-analysis of diagnostic test accuracy studies conducted in primary care was performed using a novel model that incorporates data at multiple thresholds.

Method

MEDLINE, EMBASE, and PsycINFO were searched for studies published between January 1980 and February 2019. Included studies were: cross-sectional; recruited patients with sore throats from primary care; used the Centor or McIsaac score; had GABHS infection as the target diagnosis; used throat swab culture as the reference standard; and reported 2 × 2 tables across multiple thresholds. Selection and data extraction were conducted by two independent reviewers. QUADAS-2 was used to assess study quality. Summary receiver operating characteristic (SROC) curves were synthesised. Calibration curves were used to assess the transferability of results into practice.

Results

Ten studies using the Centor score and eight using the McIsaac score were included. The prevalence of GABHS ranged between 4% and 44%. The areas under the SROC curves for McIsaac and Centor scores were 0.7052 and 0.6888, respectively. The P-value for the difference (0.0164) was 0.419, suggesting the SROC curves for the tests are equivalent. Both scores demonstrated poor calibration.

Conclusion

Both Centor and McIsaac scores provide only fair discrimination of those with and without GABHS, and appear broadly equivalent in performance. The poor calibration for a positive test result suggests other point-of-care tests are required to rule in GABHS; however, with both Centor and McIsaac scores, a score of ≤0 may be sufficient to rule out infection.

Oral cavity swabbing for diagnosis of group a Streptococcus: a prospective study

Background

Throat pain is a common complaint in the ambulatory setting. Diagnosis of group A Streptococcus is made with a culture, molecular test or a rapid antigen detection test from the tonsils or the posterior pharyngeal wall, while other areas of the oral cavity are considered unacceptable. The purpose of the study is to compare cultures from the tonsils or posterior pharyngeal wall (throat) with cultures from the oral cavity (mouth).

Methods

A prospective study conducted in ambulatory care. Eleven family physicians collected 2 swabs (throat and mouth) from 200 consecutive patients who complaint about throat pain. Inclusion criteria were throat pain and Centor Criteria > 2. Exclusion criteria were tonsillectomy and age (< 3 or > 65 years old). Participants were later divided into two groups – pediatrics (3–18 years old) and adults (19–65 year old). Sensitivity and specificity of mouth culture were calculated, with throat culture considered the reference gold standard.

Results

Between November 2017 and March 2019, 200 swabs were collected (101 adults and 99 children). In the adult group sensitivity of mouth culture was 72.1% (95% Confidence Interval [CI] 59.9–82.3%) and specificity was 100% (95% CI 92.7–89.4%-100%). In the pediatric group sensitivity of mouth culture was 78.3% (95% CI 65.8–87.9%) and specificity was 100% (95% CI 92.5–100%).

Conclusion

Our study demonstrated higher sensitivity of mouth culture for GAS than previously published. This finding suggests that areas of the oral cavity that were considered as unacceptable sites for culture of GAS pharyngitis may be considered as acceptable swabbing sites.

Trial registration

Trial registration: ClinicalTrials.gov, ID NCT03137823. Registered 3 May 2017.

Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review

BACKGROUND

Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.

METHODS

A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.

RESULTS

Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (&gt;1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P &lt; .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).

CONCLUSIONS

Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.

Prevalence of Group A Streptococcus in Primary Care Patients and the Utility of C-Reactive Protein and Clinical Scores for Its Identification in Thailand

Pharyngitis is usually caused by a viral infection for which antibiotics are often unnecessarily prescribed, adding to the burden of antimicrobial resistance. Identifying who needs antibiotics is challenging; microbiological confirmation and clinical scores are used but have limitations. In a cross-sectional study nested within a randomized controlled trial, we estimated the prevalence and antibiotic susceptibility profiles of group A Streptococcus (GAS) in patients presenting to primary care with a sore throat and fever in northern Thailand. We then evaluated the use of C-reactive protein (CRP) and clinical scores (Centor and FeverPAIN) to identify the presence of GAS. One hundred sixty-nine patients were enrolled, of whom 35 (20.7%) had β-hemolytic Streptococci (BHS) isolated from throat swab culture, and 11 (6.5%) had GAS. All GAS isolates were sensitive to penicillin G. The median CRP of those without BHS isolation was 10 mg/L (interquartile range [IQR] ≤ 8-18), compared with 18 mg/L (IQR 9-71, P = 0.0302) for those with GAS and 14 mg/L (IQR ≤ 8-38, P = 0.0516) for those with any BHS isolated. However, there were no significant relationships between CRP > 8 mg/L (P = 0.112), Centor ≥ 3 (P = 0.212), and FeverPAIN ≥ 4 (P = 1.000), and the diagnosis of GAS compared with no BHS isolation. Identifying who requires antibiotics for pharyngitis remains challenging and necessitates further larger studies. C-reactive protein testing alone, although imperfect, can reduce prescribing compared with routine care. Targeted CRP testing through clinical scoring may be the most cost-effective approach to ruling out GAS infection.

A Bayesian Spatiotemporal Analysis of Pediatric Group A Streptococcal Infections

Background

Pharyngitis due to group A Streptococcus (GAS) is a common pediatric infection. Physicians might diagnose GAS pharyngitis more accurately when given biosurveillance information about GAS activity. The availability of geographic GAS testing data may be able to assist with real-time clinical decision-making for children with throat infections.

Methods

GAS rapid antigen testing data were obtained from the records of 6086 children at Boston Children's Hospital and 8648 children at Duke University Medical Center. Records included children tested in outpatient, primary care settings. We constructed Bayesian generalized additive models, in which the outcome variable was the binary result of GAS testing, and predictor variables included smoothed functions of patient location data and both cyclic and longitudinal time data.

Results

We observed a small degree of geographic heterogeneity, but no convincing clusters of high risk. The probability of a positive test declined during the summer months.

Conclusions

Future work should include geographic data about school catchments to identify whether GAS transmission clusters within schools.

The role of real-world data in the development of treatment guidelines: a case study on guideline developers' opinions about using observational data on antibiotic prescribing in primary care

Background

Antimicrobial resistance (AMR) is a prominent threat to public health. Although many guidelines have been developed over the years to tackle this issue, their impact on health care practice varies. Guidelines are often based on evidence from clinical trials, but these have limitations, particularly in the breadth and generalisability of the evidence and evaluation of the guidelines’ uptake. The aim of this study was to investigate how national and local guidelines for managing common infections are developed and explore guideline committee members’ opinions about using real-world observational evidence in the guideline development process.

Methods

Six semi-structured interviews were completed with participants who had contributed to the development or adjustment of national or local guidelines on antimicrobial prescribing over the past 5 years (from the English National Institute for Health and Care Excellence (NICE)). Interviews were audio recorded and transcribed verbatim. Data was analysed thematically. This also included review of policy documents including guidelines, reports and minutes of guideline development group meetings that were available to the public.

Results

Three key themes emerged through our analysis: perception versus actual guideline development process, using other types of evidence in the guideline development process, and guidelines are not enough to change antibiotic prescribing behaviour. In addition, our study was able to provide some insight between the documented and actual guideline development process within NICE, as well as how local guidelines are developed, including differences in types of evidence used.

Conclusions

This case study indicates that there is the potential for a wider range of evidence to be included as part of the guideline development process at both the national and local levels. There was a general agreement that the inclusion of observational data would be appropriate in enhancing the guideline development process, as well providing a potential solution for monitoring guideline use in clinical practice, and improving the implementation of treatment guidelines in primary care.

Assessment of Pharyngitis Management at a University Student Health Services Clinic

OBJECTIVE

The objective of this study was to assess the management of students presenting with pharyngitis to a university health clinic.

METHODS

This was a retrospective cohort study. Electronic medical records of undergraduate students presenting to a university health clinic from January 1, 2012, through December 31, 2014, with complaints of sore throat and a diagnosis code for pharyngitis, tonsillitis, or sore throat were reviewed.

RESULTS

Records of 241 patients were screened and 197 patients were included. A rapid antigen detection test (RADT) was obtained in 145 (73.6%) patients. The incidence of group A streptococci (GAS) and non-GAS were 15.2% (30/197) and 10.1% (21/197), respectively. All patients with a positive RADT were prescribed antibiotics, with 13 (46.4%) receiving amoxicillin. Overall, 129 (65%) patients received an antibiotic prescription.

CONCLUSION

Management of pharyngitis at the clinic appears inconsistent with current guidelines. Approximately 2 of every 3 students were prescribed an antibiotic with no clear indication.

Impact of viral symptoms on the performance of the modified centor score to predict pediatric group A streptococcal pharyngitis

BACKGROUND

Clinicians use the Modified Centor Score (MCS) to estimate the risk of group A streptococcal (GAS) pharyngitis in children with sore throat. The Infectious Diseases Society of America (IDSA) recommends neither testing nor treating patients with specific viral symptoms. The goal of this study is to measure the impact of those symptoms on the yield of GAS testing predicted by the MCS.

METHODS

Retrospective cohort study of all patients aged 3-21 years presenting with sore throat and tested for GAS in a pediatric emergency department (ED) in 2016. After identifying all patients tested for GAS, we used natural language processing (NLP) to identify the subgroup complaining of sore throat. We abstracted all MCS variables as well as symptoms suggestive of a viral etiology per the IDSA guideline (conjunctivitis, coryza, cough, diarrhea, hoarseness, ulcerative oral lesions, viral exanthema). We calculated the proportion of patients who tested positive for GAS by MCS with and without viral symptoms.

RESULTS

Of the 1574 patients included, 372 patients (24%) tested GAS positive. Patients with at least one viral symptom had a reduced GAS risk compared to those without any of the viral symptoms 91/547 (17% GAS positive) vs. 281/1027 (27%), odds ratio 0.53 (95% CI 0.41-0.69).

CONCLUSIONS

The presence of viral symptoms specified by the IDSA alters the predicted yield of testing by traditional MCS. Clinicians may consider adjusting interpretation of a patient's MCS based on the presence of viral symptoms, but viral symptoms may not always fully obviate the need for GAS testing.

A Fungal Immunotherapeutic Vaccine (NDV-3A) for Treatment of Recurrent Vulvovaginal Candidiasis-A Phase 2 Randomized, Double-Blind, Placebo-Controlled Trial

Background

Recurrent vulvovaginal candidiasis (RVVC) is a problematic form of mucosal Candida infection, characterized by repeated episodes per year. Candida albicans is the most common cause of RVVC. Currently, there are no immunotherapeutic treatments for RVVC.

Methods

This exploratory randomized, double-blind, placebo-controlled trial evaluated an immunotherapeutic vaccine (NDV-3A) containing a recombinant C. albicans adhesin/invasin protein for prevention of RVVC.

Results

The study in 188 women with RVVC (n = 178 evaluable) showed that 1 intramuscular dose of NDV-3A was safe and generated rapid and robust B- and T-cell immune responses. Post hoc exploratory analyses revealed a statistically significant increase in the percentage of symptom-free patients at 12 months after vaccination (42% vaccinated vs 22% placebo; P = .03) and a doubling in median time to first symptomatic episode (210 days vaccinated vs 105 days placebo) for the subset of patients aged <40 years (n = 137). The analysis of evaluable patients, which combined patients aged <40 years (77%) and ≥40 years (23%), trended toward a positive impact of NDV-3A versus placebo (P = .099).

Conclusions

In this unprecedented study of the effectiveness of a fungal vaccine in humans, NDV-3A administered to women with RVVC was safe and highly immunogenic and reduced the frequency of symptomatic episodes of vulvovaginal candidiasis for up to 12 months in women aged <40 years. These results support further development of NDV-3A vaccine and provide guidance for meaningful clinical endpoints for immunotherapeutic management of RVVC.

Clinical Trials Registration

NCT01926028.

Developing a framework for evidence-based grading and assessment of predictive tools for clinical decision support

BACKGROUND

Clinical predictive tools quantify contributions of relevant patient characteristics to derive likelihood of diseases or predict clinical outcomes. When selecting predictive tools for implementation at clinical practice or for recommendation in clinical guidelines, clinicians are challenged with an overwhelming and ever-growing number of tools, most of which have never been implemented or assessed for comparative effectiveness. To overcome this challenge, we have developed a conceptual framework to Grade and Assess Predictive tools (GRASP) that can provide clinicians with a standardised, evidence-based system to support their search for and selection of efficient tools.

METHODS

A focused review of the literature was conducted to extract criteria along which tools should be evaluated. An initial framework was designed and applied to assess and grade five tools: LACE Index, Centor Score, Well's Criteria, Modified Early Warning Score, and Ottawa knee rule. After peer review, by six expert clinicians and healthcare researchers, the framework and the grading of the tools were updated.

RESULTS

GRASP framework grades predictive tools based on published evidence across three dimensions: 1) Phase of evaluation; 2) Level of evidence; and 3) Direction of evidence. The final grade of a tool is based on the highest phase of evaluation, supported by the highest level of positive evidence, or mixed evidence that supports a positive conclusion. Ottawa knee rule had the highest grade since it has demonstrated positive post-implementation impact on healthcare. LACE Index had the lowest grade, having demonstrated only pre-implementation positive predictive performance.

CONCLUSION

GRASP framework builds on widely accepted concepts to provide standardised assessment and evidence-based grading of predictive tools. Unlike other methods, GRASP is based on the critical appraisal of published evidence reporting the tools' predictive performance before implementation, potential effect and usability during implementation, and their post-implementation impact. Implementing the GRASP framework as an online platform can enable clinicians and guideline developers to access standardised and structured reported evidence of existing predictive tools. However, keeping GRASP reports up-to-date would require updating tools' assessments and grades when new evidence becomes available, which can only be done efficiently by employing semi-automated methods for searching and processing the incoming information.

Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study

OBJECTIVE

To determine whether total exposure to penicillin V can be reduced while maintaining adequate clinical efficacy when treating pharyngotonsillitis caused by group A streptococci.

DESIGN

Open label, randomised controlled non-inferiority study.

SETTING

17 primary healthcare centres in Sweden between September 2015 and February 2018.

PARTICIPANTS

Patients aged 6 years and over with pharyngotonsillitis caused by group A streptococci and three or four Centor criteria (fever ≥38.5°C, tender lymph nodes, coatings of the tonsils, and absence of cough).

INTERVENTIONS

Penicillin V 800 mg four times daily for five days (total 16 g) compared with the current recommended dose of 1000 mg three times daily for 10 days (total 30 g).

MAIN OUTCOME MEASURES

Primary outcome was clinical cure five to seven days after the end of antibiotic treatment. The non-inferiority margin was prespecified to 10 percentage points. Secondary outcomes were bacteriological eradication, time to relief of symptoms, frequency of relapses, complications and new tonsillitis, and patterns of adverse events.

RESULTS

Patients (n=433) were randomly allocated to the five day (n=215) or 10 day (n=218) regimen. Clinical cure in the per protocol population was 89.6% (n=181/202) in the five day group and 93.3% (n=182/195) in the 10 day group (95% confidence interval -9.7 to 2.2). Bacteriological eradication was 80.4% (n=156/194) in the five day group and 90.7% (n=165/182) in the 10 day group. Eight and seven patients had relapses, no patients and four patients had complications, and six and 13 patients had new tonsillitis in the five day and 10 day groups, respectively. Time to relief of symptoms was shorter in the five day group. Adverse events were mainly diarrhoea, nausea, and vulvovaginal disorders; the 10 day group had higher incidence and longer duration of adverse events.

CONCLUSIONS

Penicillin V four times daily for five days was non-inferior in clinical outcome to penicillin V three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci. The number of relapses and complications did not differ between the two intervention groups. Five day treatment with penicillin V four times daily might be an alternative to the currently recommended 10 day regimen.

TRIAL REGISTRATION

EudraCT 2015-001752-30; ClinicalTrials.gov NCT02712307.

Role of epidemiological risk factors in improving the clinical diagnosis of streptococcal sore throat in pediatric clinical practice

BACKGROUND AND AIMS

Antibiotics are frequently prescribed for sore throat in developing countries, that in turn leads to huge healthcare expenditure and their irrational use may lead to antimicrobial resistance in the community. The aim of this study is to investigate the effect of environmental factors on the frequency of occurrence of group A beta hemolytic streptococcus (GABHS) sore throat and to work out enhancing effect on the sensitivity and specificity and positive predictive value of the signs and symptoms of GABHS sore throat for facilitation of rational antibiotic use.

SETTINGS AND DESIGN

This was a prospective, cross sectional study conducted over period of one year in Pediatric Outpatient Department (OPD) of a Tertiary care teaching hospital.

METHODS

All the children between the age of 5 years and 15 years of age presenting in OPD with the signs and symptoms of sore throat were included in the study.

STATISTICAL ANALYSIS USED

Statistical analysis was carried out by using Statistical Package for Social Sciences software and statistical tests of Pearson's Coefficient, Chi-square Test, Fischer's Test, Likelihood Ratio, Odds Ratio, and ROC Curve were applied.

RESULTS

Out of 225 children of the study group, 153 (68%) of the children were in the 5-10 years' age group. Positive throat swab culture was found to be positively associated with high grade fever, pain in throat while swallowing, severely enlarged tonsils, tender lymphadenopathy, poor housing condition, fuel used for cooking, and presence of smoker in house.

CONCLUSIONS

The study stresses on the need of carefully evaluating children presenting with the symptoms of sore throat as majority of the cases may be viral and thus, self-limiting. Poor housing conditions and indoor pollution contribute to the increased prevalence of sore throat.

Patient Satisfaction and Antibiotic Prescribing for Respiratory Infections by Telemedicine

BACKGROUND AND OBJECTIVES

Respiratory tract infections (RTIs) are a common reason for direct-to-consumer (DTC) telemedicine consultation. Antibiotic prescribing during video-only DTC telemedicine encounters was explored for pediatric RTIs.

METHODS

Encounter data were obtained from a nationwide DTC telemedicine platform. Mixed-effects regression was used to assess variation in antibiotic receipt by patient and physician factors as well as the association between antibiotic receipt and visit length or patient satisfaction.

RESULTS

Of 12 842 RTI encounters with 560 physicians, antibiotics were prescribed in 55%. The provider was more likely to receive a 5-star rating from the parent when an antibiotic was prescribed (93.4% vs 80.8%). A 5-star rating was associated with a prescription for an antibiotic (odds ratio [OR] 3.38; 95% confidence interval [CI] 2.84 to 4.02), an antiviral (OR 2.56; 95% CI 1.81 to 3.64), or a nonantibiotic (OR 1.93; 95% CI 1.58 to 2.36). Visit length was associated with higher odds of a 5-star rating only when no antibiotic was prescribed (OR 1.03 per 6 seconds; 95% CI 1.01 to 1.06). Compared with nonpediatricians, pediatric providers were less likely to prescribe antibiotics (OR 0.44; 95% CI 0.29 to 0.68); however, pediatricians received higher encounter satisfaction ratings (OR 1.50; 95% CI 1.11 to 2.03).

CONCLUSIONS

During DTC telemedicine consultations for RTIs, pediatric patients were frequently prescribed antibiotics, which correlated with visit satisfaction. Although pediatricians prescribed antibiotics at a lower rate than other physicians, their satisfaction scores were higher. Further work is required to ensure that antibiotic use during DTC telemedicine encounters is guideline concordant.

Implementation of a Highly Accurate Rapid Point-of-Care Test for Group a Streptococcus Detection at a Large Pediatric Emergency Department in South London

Rapid group A Streptococcus point-of-care testing is not currently used in the United Kingdom in the management of acute tonsillitis. This prospective, observational study describes a strong association between a molecular-based point-of-care testing result and outpatient antibiotic prescribing (odds ratio = 48; P < 0.001) in 339 children seen at our center. It highlights challenges in implementing new rapid diagnostics.

Clinical gestalt to diagnose pneumonia, sinusitis, and pharyngitis: a meta-analysis

BACKGROUND

The overall clinical impression ('clinical gestalt') is widely used for diagnosis but its accuracy has not been systematically studied.

AIM

To determine the accuracy of clinical gestalt for the diagnosis of community-acquired pneumonia (CAP), acute rhinosinusitis (ARS), acute bacterial rhinosinusitis (ABRS), and streptococcal pharyngitis, and to contrast it with the accuracy of clinical decision rules (CDRs).

DESIGN AND SETTING

Systematic review and meta-analysis of outpatient diagnostic accuracy studies in ambulatory care.

METHOD

PubMed and Google were searched for studies in outpatients that reported sufficient data to calculate accuracy of the overall clinical impression and that used the same reference standard. Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2), and measures of accuracy calculated using bivariate meta-analysis.

RESULTS

The authors identified 16 studies that met the inclusion criteria. The summary estimates for the positive (LR+) and negative likelihood ratios (LR-) were LR+ 7.7, 95% confidence interval (CI) = 4.8 to 11.5, and LR- 0.54, 95% CI = 0.42 to 0.65 for CAP in adults, LR+ 2.7, 95% CI = 1.1 to 4.3 and LR- 0.63, 95% CI = 0.20 to 0.98 for CAP in children, LR+ 3.0, 95% CI = 2.1 to 4.4 and LR- 0.37, 95% CI = 0.29 to 0.46 for ARS in adults, LR+ 3.9, 95% CI = 2.4 to 5.9 and LR- 0.33, 95% CI = 0.20 to 0.50 for ABRS in adults, and LR+ 2.1, 95% CI = 1.6 to 2.8 and LR- 0.47, 95% CI = 0.36 to 0.60 for streptococcal pharyngitis in adults and children. The diagnostic odds ratios were highest for CAP in adults (14.2, 95% CI = 9.0 to 21.0), ARS in adults (8.3, 95% CI = 4.9 to 13.1), and ABRS in adults (13.0, 95% CI = 5.0 to 27.0), as were the C-statistics (0.80, 0.77, and 0.84 respectively).

CONCLUSION

The accuracy of the overall clinical impression compares favourably with the accuracy of CDRs. Studies of diagnostic accuracy should routinely include the overall clinical impression in addition to individual signs and symptoms, and research is needed to optimise its teaching.

Management of sore throat in Danish general practices

BACKGROUND

The national guideline for sore throat, endorsed by the Danish Society of General Medicine, recommends the use of the modified Centor score and streptococcal rapid antigen detection test to guide diagnosis and treatment of sore throat. The aim was to investigate Danish general practitioners (GPs) routine management of sore throat patients with a focus on the modalities used and adherence to the guideline.

METHODS

A cross-sectional study. GPs in the Central Denmark Region answered an online questionnaire in October 2017. The main outcome measure was modalities used in the management of sore throat patients.

RESULTS

In total, 266 of 500 (53%) GPs answered the survey. Ten percent of participants were adherent or almost adherent to the guideline, while 82% of GPs added one or more extra modalities (general clinical assessment (67%), biochemical parameters (48%), and throat swabs for bacterial culture (18%)) to differentiate viral and bacterial etiology. Sixty-five percent of participants used the Centor Score or modified Centor Score, 96% of GPs used a streptococcal rapid antigen detection test, and all GPs chose narrow-spectrum penicillin as the first-line antibiotic. The most common reasons for non-adherence to the guideline were greater confidence in the clinical assessment (39%), time pressure (33%), and difficulty recalling the guideline (19%).

CONCLUSION

Danish GPs rarely adhere to the recommended sore throat management guideline, but use various combinations of different modalities in the assessment of bacterial infection. This practice may increase antibiotic prescription rates.

Streptococcus pyogenes evades adaptive immunity through specific IgG glycan hydrolysis

EndoS from Streptococcus pyogenes hydrolyzes the functionally important glycan on the Fc portion of IgG during infections in humans. In mice with IgG mediated immunity against the M1 protein on the bacteria, EndoS is a virulence factor.

Streptococcus pyogenes (Group A streptococcus; GAS) is a human pathogen causing diseases from uncomplicated tonsillitis to life-threatening invasive infections. GAS secretes EndoS, an endoglycosidase that specifically cleaves the conserved N-glycan on IgG antibodies. In vitro, removal of this glycan impairs IgG effector functions, but its relevance to GAS infection in vivo is unclear. Using targeted mass spectrometry, we characterized the effects of EndoS on host IgG glycosylation during the course of infections in humans. Substantial IgG glycan hydrolysis occurred at the site of infection and systemically in the severe cases. We demonstrated decreased resistance to phagocytic killing of GAS lacking EndoS in vitro and decreased virulence in a mouse model of invasive infection. This is the first described example of specific bacterial IgG glycan hydrolysis during infection and thereby verifies the hypothesis that EndoS modifies antibodies in vivo. This mechanisms of immune evasion could have implications for treatment of severe GAS infections and for future efforts at vaccine development.

Useful manifestations to detect adenovirus in children with upper respiratory infections: A retrospective study

OBJECTIVE

Approximately 1 million adenovirus immunochromatography (IC) kits are annually used in Japan. However, no practical strategies have been developed regarding their use for detecting adenovirus. The present study aims to verify the usefulness of clinical manifestations in making decisions regarding the use of adenovirus IC kits for children with upper respiratory infections (URI).

METHODS

The medical records of 825 pediatric cases tested by IC kits for adenovirus were extracted from clinical laboratory department database over a 3-year period at our hospital. Among them, 585 patients were suspected adenovirus URI, and their clinical manifestations were reviewed. After data cleaning, 10 types of clinical manifestations were statistically analyzed between adenovirus IC kit-positive and -negative groups. Multivariate analysis was performed to select significant clinical manifestations using adenovirus IC kit positivity as the objective variable.

RESULTS

Among 585 pediatric patients, the cases of 420 patients, with suitable data for whom no other pathogen was detected, were reviewed. Adenovirus was detected in 86 cases. Multivariate analysis identified a significant difference for three clinical manifestations: (1) fever ≥ 39.0°C, (2) rhinorrhea, and (3) tonsillar exudate. The negativity rate for the IC kit was 90% when none of the three manifestations was observed.

CONCLUSIONS

The results suggested that IC kits for adenovirus tend to give negative results in cases that lack all the three above mentioned clinical manifestations.

Use of point-of-care tests and antibiotic prescribing in sore throat and lower respiratory infections by general practitioners

INTRODUCTION

This study was aimed at assessing general practitioners' (GP) reliance on patient history, examination findings and the influence of the utilisation of point-of-care tests (POCT) in antibiotic prescribing for sore throat and lower respiratory tract infections (LRTI).

METHODS

Audit-based study carried out in 2015. A group of GPs received an intervention six years earlier with provision of POCTs and another group of GPs acted as controls. Odds ratios for clinical variables predicting antibiotic prescribing were calculated by logistic regression analyses.

RESULTS

A total of 238 GPs included 1906 patients with sore throat and 1970 LRTIs. A negative POCT result was negatively associated with antibiotic prescribing, with odds ratios ranging from 0.09 to 0.23. GPs using POCTs attached less weight to clinical criteria.

CONCLUSION

GPs using rapid tests are mainly influenced by POCT results in the decision to prescribe antibiotics. However, antibiotic prescribing is still observed with negative POCT results.

Signs and Symptoms That Rule out Community-Acquired Pneumonia in Outpatient Adults: A Systematic Review and Meta-Analysis

BACKGROUND

A systematic review of clinical decision rules to identify patients at low risk for community-acquired pneumonia (CAP) has not been previously presented in the literature.

METHODS

A systematic review of MEDLINE for prospective studies that used at least 2 signs, symptoms, or point-of-care tests to determine the likelihood of CAP. We included studies that enrolled adults and adolescents in the outpatient setting where all or a random sample of patients received a chest radiograph as the reference standard. We excluded retrospective studies and studies that recruited primarily patients with hospital-acquired CAP.

RESULTS

Our search identified 974 articles, 12 of which were included in the final analysis. The simple heuristic of normal vital signs (temperature, respiratory rate, and heart rate) to identify patients at low risk for CAP was reported by 4 studies and had a summary estimate of the negative likelihood ratio (LR-) of 0.24 (95% CI, 0.17 to 0.34) and a sensitivity of 0.89 (95% CI, 0.79 to 0.94). The simple heuristic of normal vital signs combined with a normal pulmonary examination to identify patients at low risk for CAP was reported by 3 studies, and had a summary estimate of LR- of 0.10 (95% CI, 0.07 to 0.13) with an area under the receiver operating characteristic curve of 0.92.

CONCLUSIONS

Adults with an acute respiratory infection who have normal vital signs and a normal pulmonary examination are very unlikely to have CAP. Given a baseline CAP risk of 4%, these patients have only a 0.4% likelihood of CAP.

Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis

PURPOSE

To evaluate the accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis (ARS).

METHODS

We searched Medline to identify studies of outpatients with clinically suspected ARS and sufficient data reported to calculate the sensitivity and specificity. Of 1,649 studies initially identified, 17 met our inclusion criteria. Acute rhinosinusitis was diagnosed by any valid reference standard, whereas acute bacterial rhinosinusitis (ABRS) was diagnosed by purulence on antral puncture or positive bacterial culture. We used bivariate meta-analysis to calculate summary estimates of test accuracy.

RESULTS

Among patients with clinically suspected ARS, the prevalence of imaging confirmed ARS is 51% and ABRS is 31%. Clinical findings that best rule in ARS are purulent secretions in the middle meatus (positive likelihood ratio [LR+] 3.2) and the overall clinical impression (LR+ 3.0). The findings that best rule out ARS are the overall clinical impression (negative likelihood ratio [LR-] 0.37), normal transillumination (LR- 0.55), the absence of preceding respiratory tract infection (LR- 0.48), any nasal discharge (LR- 0.49), and purulent nasal discharge (LR- 0.54). Based on limited data, the overall clinical impression (LR+ 3.8, LR- 0.34), cacosmia (fetid odor on the breath) (LR+ 4.3, LR- 0.86) and pain in the teeth (LR+ 2.0, LR- 0.77) are the best predictors of ABRS. While several clinical decision rules have been proposed, none have been prospectively validated.

CONCLUSIONS

Among patients with clinically suspected ARS, only about one-third have ABRS. The overall clinical impression, cacosmia, and pain in the teeth are the best predictors of ABRS. Clinical decision rules, including those incorporating C-reactive protein, and use of urine dipsticks are promising, but require prospective validation.

Assessment of Test Performance and Potential for Environmental Contamination Associated with a Point-of-Care Molecular Assay for Group A Streptococcus in an End User Setting

Although U.S. Food and Drug Administration-approved and CLIA-waived point-of-care (POC) molecular systems are being implemented in routine clinical practice, instrument reliability, test performance in the hands of end users, and the potential for environmental contamination resulting from use of POC molecular systems have not been extensively evaluated. We performed a prospective evaluation of the Roche cobas Liat group A streptococcus (GAS) assay compared to routine real-time PCR. We evaluated test accuracy, instrument failure rate, and monitored for environmental contamination when testing was performed by minimally trained end users in an Express Care Clinic environment. The overall concordance of the Liat GAS assay with routine testing was 97.2% (455/468). The average Liat failure rate across three analyzers was 6.6% (33/501) (range, 3.7 to 11.6%), and no environmental contamination was detected during the course of the study. The cobas Liat platform and GAS assay demonstrated reliable performance in the end user setting and may serve as a rapid, POC option for routine diagnostic testing for certain infectious diseases, including GAS.

Association between rapid antigen detection tests and antibiotics for acute pharyngitis in Japan: A retrospective observational study

The application and clinical impact of rapid antigen detection test (RADT) in the treatment of acute pharyngitis is unknown in Japan. We aimed to examine the proportions of RADT usage to identify Group A β-hemolytic Streptococcus (GAS) in outpatients with acute pharyngitis and evaluate the association between RADT and antibiotic treatment. We analyzed health insurance claims data from 2013 to 2015. Logistic regression models were used to analyze associated factors with RADT, overall antibiotic prescription, or penicillin use. We analyzed 1.27 million outpatient visits with acute pharyngitis, in which antibiotics were prescribed in 59.3% of visits. Of the total visits, 5.6% of patients received RADT, and 10.8% of the antibiotics were penicillin. Penicillin selection rates were higher in cases with RADT (25.4%) than those without RADT (9.7%). Compared to large-scale facilities, antibiotic prescription rates were higher in physicians' offices. For factor analysis, age (3-15 years), diagnosis code (streptococcal pharyngitis), size of the medical facility (large-scale hospitals), and physician's specialty (pediatrics) were associated with RADT use. Penicillin selection rate increased with RADT implementation (25.4% vs. 9.7%: adjusted odds ratio 1.55; 95% CI, 1.50-1.60). At 63% of the facilities, the RADT implementation rate was <5% of acute pharyngitis visits prescribed antibiotics. In conclusion, the proportion of RADT usage for outpatients with acute pharyngitis was low in Japan. With appropriate indication and evaluation, we expect that more utilization of RADT can help promote antimicrobial stewardship for outpatients with acute pharyngitis by prompting penicillin therapy. Further investigation with detailed clinical data are warranted.

Infections of the Neck

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.

Clinical Screening Tools to Diagnose Group A Streptococcal Pharyngotonsillitis in Primary Care Clinics to Improve Prescribing Habits

This review highlights the clinical scoring tools used for the management of acute pharyngotonsillitis in primary care clinics. It will include the prevalence of group A pharyngotonsillitis among children and adults worldwide and the selective tests employed for diagnosing group A streptococcal pharyngotonsillitis. Pharyngotonsillitis is one of the common reasons for visits to primary care clinics worldwide, and physicians tend to prescribe antibiotics according to the clinical symptoms, which leads to overprescribing antibiotics. This in turn may lead to serious health impacts and severe reactions and may promote antibiotic resistance. These significantly add on to the health care costs. The available information from health organisations and previous studies has indicated the need to manage the diagnosis of pharyngotonsillitis to improve prescribing habits in primary care clinics.

Diagnosis and treatment of community-acquired pneumonia in patients with acute cough: a quantitative study of decision thresholds in primary care

BACKGROUND

Test and treatment thresholds have not yet been described for decision-making regarding the likelihood of pneumonia in patients with acute cough.

AIM

To determine decision thresholds in the management of patients with acute cough.

DESIGN AND SETTING

Set among primary care physicians attending meetings in the US and Switzerland, using data from a prospective cohort of primary care patients.

METHOD

Clinical vignettes were used to study the clinical decisions of physicians regarding eight patients with cough that varied by six signs and symptoms. The probability of community-acquired pneumonia (CAP) was determined for each vignette based on a multivariate model. A previously published approach based on logistic regression was used to determine test and treatment thresholds.

RESULTS

In total, 256 physicians made 764 clinical decisions. Initial physician estimates systematically overestimated the likelihood of CAP; 75% estimating a higher probability than that predicted by the multivariate model. Given the probability of CAP from a multivariate model, 16.7% (125 of 749) changed their decision from 'treat' to 'test' or 'test' to 'rule out', whereas only 3.5% (26/749) changed their decision from 'rule out' to 'test' or 'test' to 'treat'. Test and treatment thresholds were 9.5% (95% confidence interval (CI) = 8.7 to 10.5) and 43.1% (95% CI = 40.1 to 46.4) and were updated to 12.7% (95% CI = 11.7 to 13.8) and 51.3% (95% CI = 48.3 to 54.9) once the true probability of CAP was given. Test thresholds were consistent between subgroups. Treatment thresholds were higher if radiography was available, for Swiss physicians, and for non-primary care physicians.

CONCLUSION

Test and treatment thresholds for CAP in patients with acute cough were 9.5% and 43.1%, respectively. Physicians tended to overestimate the likelihood of CAP, and providing information from a clinical decision rule (CDR) changed about 1 in 6 clinical decisions.

Protection against the overuse and underuse of health care - methodological considerations for establishing prioritization criteria and recommendations in general practice

BACKGROUND

Initiatives such as "Choosing Wisely" in the USA and "Smarter Medicine" in Switzerland have published lists of widely overused health care services. The German initiative "Choosing Wisely Together (Gemeinsam Klug Entscheiden)" follows this example. The goal of our study was to prioritize important recommendations against the overuse and underuse of health care services. The final list of recommendations will be published in the German guideline "Protection against the overuse and underuse of health care".

METHODS

First, a multidisciplinary expert panel established a catalogue of prioritization criteria. Second, we extracted all the recommendations from evidence- and consensus-based German College of General Practice and Family Medicine (DEGAM) guidelines and National Health Care Guidelines (NVL). Third, the recommendations were rated by two independent panels (general practitioners and other health care professionals involved/not involved in guideline development). The prioritization process was finalized in a consensus conference held by DEGAM's Standing Guideline Committee (SLK).

RESULTS

Eleven prioritization criteria were established. A total of 782 recommendations were extracted and rated by 98 physicians and other health care professionals in a survey. In the voting process, more than 80% of the recommendations were eliminated. After the final consensus conference, twelve recommendations from DEGAM guidelines, nine DEGAM addenda and 17 NVL recommendations were chosen for inclusion in the guideline, for a total of 38 recommendations.

CONCLUSION

The selection procedure proved helpful in identifying the highest priority recommendations with which to combat the overuse and underuse of health care services. To date, in Germany there has been no attempt to compile such a list by using a systematic and transparent methodology. Hence, the guideline that results from this process can fill an important gap.

Estudio Prospectivo Observacional: Determinar la Sensibilidad del Criterio Clínico usando la Escala de “Centor” versus el Test de Detección Rápida de Estreptococo para el diagnóstico de Faringitis Estreptocócica del Grupo A en el Centro de Salud Bárbara

Introducción: Las faringitis producidas por el estreptococo beta hemolítico del grupo A no se pueden distinguir clínicamente de las faringitis producidas por otros gérmenes, sin embargo la utilización de los criterios de Centor y el test de detección rápida de antígeno son de gran utilidad para determinar las probabilidades que estos sean causados por el estreptococo beta hemolítico del grupo A. En este estudio se comparó la sensibilidad entre ambos métodos. Objetivos: Se realizó un estudio para determinar la sensibilidad del criterio clínico en el diagnóstico de faringitis causada por Estreptococo en comparación a la sensibilidad del test de detección rápida de antígeno. Metodología: En el Centro de Salud Bárbara, se tomaron a los pacientes pediátricos que consultaron por dolor de garganta durante dos meses. Se puntuó según la escala de Centor y se tomó una muestra para el test de detección rápida de antígeno, luego, se comparó con el cultivo de orofaringe. Resultados: Se comparó la sensibilidad de ambos parámetros. Discusión: Un puntaje ≥ 3 puntos en la escala de Centor tuvo una sensibilidad de 81.8% y especificidad de 50%. Mientras que el RADT presentó una sensibilidad del 83.3% y especificidad de 84.2%.

Rapid antigen test use for the management of group A streptococcal pharyngitis in community pharmacies

Despite group A streptococci being an infrequent cause of pharyngitis in adult outpatients, sore throat remains a common indication for antibiotic prescription. This prospective multicentre non-randomised study describes a community pharmacy-based antimicrobial stewardship intervention consisting in the implementation of rapid antigen testing (RAT) for the management of adults with sore throat. Trained pharmacists triaged patients presenting with symptoms of pharyngitis using the modified Centor score. Those at risk for streptococcal infection were tested with RAT. Patients with a positive RAT were invited to consult a physician, whereas others were offered a symptomatic treatment. All patients received educational leaflets and were asked to fill in a follow-up form 7 days later. Ninety-eight pharmacies in one French region participated, and 559 patients were included over 6 months. RAT was proposed in 367 (65.7%) cases, and it was positive in 28 (8.3%). The follow-up form was returned by 140 (38.5%) participants. Of these, 10/10 patients with positive RAT further consulted a physician and were prescribed an antibiotic treatment, whereas 96.5% (110/114) of patients with negative results and not having any other reason to seek for doctor's advice did not consult. All participants found the intervention useful. Pharmacists spent 6-15 min to perform the intervention, and 98.6% (73/74) of pharmacists giving a feedback declared to be ready to implement this intervention in daily practice, if endorsed and reimbursed. Our results suggest that a pharmacy-based programme for the management of sore throat is feasible and could increase adherence to guidelines.

Acute Pharyngitis Associated With Streptococcus dysgalactiae Subspecies equisimilis in Children

BACKGROUND AND OBJECTIVES

The importance of Streptococcus dysgalactiae subsp. equisimilis (SDSE) in causing sporadic pharyngitis in children remains controversial. The aims of this study were (1) to report the incidence and (2) to compare the epidemiologic and clinical features of patients with SDSE to those with Streptococcus pyogenes (SP).

METHODS

A prospective study was conducted on acute pharyngitis associated with SDSE in children over a 2-year period. SDSE was identified using a phenotypic method, M protein gene (emm) analysis and matrix-assisted laser desorption ionization-time of flight mass spectrometry. Patients with positive SDSE or SP cultures received cephalosporins for 5 days and were followed up. The emm genotyping and specific virulence genes analyses were performed.

RESULTS

From 3416 throat cultures, 67 isolates (2.0%) were identified as SDSE and 515 (15.1%) were identified as SP. The mean age of patients with SDSE (8.3 years) was older than those with SP (6.6 years; P < 0.01). There was minimal seasonal variation in the isolation rates of SDSE. The febrile patients' rates, gender distribution, cervical lymph node adenopathy rates, hospitalization rates, eradication and failure rates and the nonsuppurative sequelae between patients with SDSE and SP were similar. All SDSE isolates possessed important virulence genes. The emm genotyping of SDSE showed high strain diversity.

CONCLUSIONS

The incidence of acute pharyngitis associated with accurately identified SDSE was 2/15 of that with SP. Epidemiologic and clinical features of acute pharyngitis associated with SDSE are indistinguishable from those with SP, with the exception of age and seasonal variation.

Signs and symptoms of Group A versus Non-Group A strep throat: A meta-analysis

INTRODUCTION

Both non-Group A streptococcal (non-GAS) pharyngitis and Group A streptococcal (GAS) pharyngitis are commonly found in patients with sore throat. It is not known whether or not they present with similar signs and symptoms compared to patients with non-streptococcal pharyngitis.

METHODS

MEDLINE was searched for prospective studies that reported throat culture for both GAS and non-GAS as a reference standard, and reported at least one sign, symptom, or the Centor score. Summary estimates of sensitivity, specificity, likelihood ratios (LR+ and LR-), and diagnostic odds ratios (DOR) were calculated using a bivariate random effects model. Summary receiver operating characteristic (ROC) curves were created for key signs and symptoms.

RESULTS

Eight studies met our inclusion criteria. Tonsillar exudate had the highest LR+ for both GAS and non-GAS pharyngitis (1.53 versus 1.71). The confidence intervals of sensitivity, LR+, LR-, and DOR for all signs, symptoms, and the Centor score between two groups overlapped, with the relative difference between sensitivities within 15% for arthralgia or myalgia, fever, injected throat, tonsillar enlargement, and tonsillar exudate. Larger differences in sensitivities were observed for sore throat, cervical adenopathy, and lack of a cough, although the difference for lack of a cough largely due to a single outlier.

DISCUSSION

Signs and symptoms of patients with GAS and non-GAS pharyngitis are generally similar. No signs or symptoms clearly distinguish GAS from non-GAS infection. Further work is needed to determine whether Group C streptococcus is a pathogen that should be treated.