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Woldan-Gradalska P, Gradalski W, Gunnarsson RK, Sundvall PD, Rystedt K. Is Streptococcus pyogenes a pathogen or passenger in uncomplicated acute sore throat? A systematic review and meta-analysis. Int J Infect Dis 2024; 145:107100. [PMID: 38762046 DOI: 10.1016/j.ijid.2024.107100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/20/2024] Open
Abstract
OBJECTIVES The objective was to estimate the probability that finding a Streptococcus pyogenes (Group A Streptococcus) in a throat swab in a patient with a sore throat reflects the aetiology. We also investigated to what extent this is influenced by age, carrier rates of S. pyogenes and climate zone. METHODS We conducted a comprehensive search of Medline and Scopus up until October 2023 for case-control studies reporting the prevalence of S. pyogenes in patients with a sore throat and healthy controls. We only included studies with separate data for children and adults. We used the positive and negative etiologic predictive values (P-EPV and N-EPV) to estimate the probability of a link between a sore throat and a finding of S. pyogenes. RESULTS We included 15 studies in our meta-analysis. The overall P-EPV for children and adults were 63% (49-74%) and 92% (87-95%), respectively. The P-EPV rose to 83% (64-93%) for children and 94% (90-97%) for adults when only patients with 3-4 Centor criteria were included. The overall N-EPV was 97% (96-98%) for children and 96% (95-97%) for adults. CONCLUSION Detecting S. pyogenes in adult patients with an uncomplicated acute sore throat is useful to rule in S. pyogenes as the likely aetiologic agent. The P-EPV significantly increased for children when those with 3-4 Centor criteria were selected. A negative throat swab is always useful for both children and adults to rule out S. pyogenes as the cause of sore throat.
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Affiliation(s)
- Patrycja Woldan-Gradalska
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden; Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden; Sätila Primary Health Care Centre, Sätila, Sweden.
| | | | - Ronny K Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden; Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden; The Primary Health Care Clinic for Homeless People, Göteborg, Sweden.
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden; Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden.
| | - Karin Rystedt
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden; Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden; Närhälsan Hentorp Primary Health Care Centre, Skövde, Sweden.
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Sapozhnikov J, Albarillo FS, Pulia MS. Optimizing Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin North Am 2024; 42:443-459. [PMID: 38641398 DOI: 10.1016/j.emc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.
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Affiliation(s)
- Julia Sapozhnikov
- Medical Science Liaison, Karius Inc, 975 Island Drive, Redwood City, CA 94065, USA
| | - Fritzie S Albarillo
- Department of Medicine, Infectious Diseases Division, Loyola University Medical Center, Loyola University Medical Center is 2160 South First Avenue, Maywood, IL 60153, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
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Kanagasabai A, Evans C, Jones HE, Hay AD, Dawson S, Savović J, Elwenspoek MMC. Systematic review and meta-analysis of the accuracy of McIsaac and Centor score in patients presenting to secondary care with pharyngitis. Clin Microbiol Infect 2024; 30:445-452. [PMID: 38182052 DOI: 10.1016/j.cmi.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 12/11/2023] [Accepted: 12/24/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Centor and McIsaac scores are clinical prediction rules for diagnosing group A streptococcus (GAS) infection in patients with pharyngitis. Their recommended thresholds vary between guidelines. OBJECTIVES To estimate the sensitivity and specificity of the McIsaac and Centor scores to diagnose GAS pharyngitis and evaluate their impact on antibiotic prescribing at each threshold in patients presenting to secondary care. DATA SOURCES MEDLINE, Embase, and Web of Science were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA Studies of patients presenting with acute pharyngitis to emergency or outpatient clinics that estimated the accuracy of McIsaac or Centor scores against throat cultures and/or rapid antigen detection tests (RADT) as reference standards. TESTS Centor or McIsaac score. REFERENCE STANDARD Throat cultures and/or RADT. ASSESSMENT OF RISK OF BIAS Quality Assessment of Diagnostic Accuracy Studies. METHODS OF DATA SYNTHESIS The sensitivities and specificities of the McIsaac and Centor scores were pooled at each threshold using bivariate random effects meta-analysis. RESULTS Fourteen studies were included (eight McIsaac and six Centor scores). Eight studies had unclear and six had a high risk of bias. The McIsaac score had higher estimated sensitivity and lower specificity relative to Centor scores at equivalent thresholds but with wide and overlapping confidence regions. Using either score as a triage to RADT to decide antibiotic treatment would reduce antibiotic prescription to patients with non-GAS pharyngitis relative to RADT test for everyone, but also reduce antibiotic prescription to patients with GAS. DISCUSSION Centor and McIsaac scores are equally ineffective at triaging patients who need antibiotics presenting with pharyngitis at hospitals. At high thresholds, too many true positive cases are missed, whereas at low thresholds, too many false positives are treated, leading to the over prescription of antibiotics. The former may be compensated by adequate safety netting by clinicians, ensuring that patients can seek help if symptoms worsen.
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Affiliation(s)
| | - Callum Evans
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Martha M C Elwenspoek
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Peiter T, Haering M, Bradic S, Coutinho G, Kostev K. Reducing Antibiotic Misuse through the Use of Point-of-Care Tests in Germany: A Survey of 1257 Medical Practices. Healthcare (Basel) 2023; 11:2466. [PMID: 37685500 PMCID: PMC10487863 DOI: 10.3390/healthcare11172466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Though more than 80% of acute pharyngitis (AP) cases have a viral etiology, it remains one of the most common causes for the unnecessary prescription of antibiotics (ABs). Half of patients receive antibiotics in general practice. Point-of-Care Tests (POCTs) distinguish between bacterial and viral pharyngitis. The objective of this study was to evaluate the use of POCTs using throat swabs to detect β-Streptococcus pyogenes Group A (strep A) infection among patients with sore throat/acute pharyngitis in primary care practices across Germany. A study was conducted in 1257 primary care practices. Two questionnaires were administered concerning frequency, POCT results and whether antibiotics were prescribed. Of the 1257 physicians, 60% used POCTs. Of these, 25% used a POCT before prescribing an antibiotic, 39% in cases of severe sore throat, 40% in cases of long-lasting pharyngitis and 25% in other cases. In total, 83% considered the adoption of POCTs in everyday practice to be important or very important for the diagnosis of strep A, 90% considered it important or very important for achieving a more sensible use of antibiotics and the prevention of bacterial resistance and 80% considered it important or very important for justifying to patients whether or not an antibiotic is needed. POCT results and information on AB prescriptions were available for 583 patients. Of these, 22.5% tested positive for strep A, and 21.8% were prescribed antibiotics. Our study shows that the use of swab tests in patients with sore throat in primary care practices results in high levels of physician satisfaction and can strongly reduce the misuse of antibiotics in clinical practice.
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Affiliation(s)
- Tina Peiter
- Reckitt Benckiser Deutschland GmbH, 69115 Heidelberg, Germany; (M.H.)
| | - Monika Haering
- Reckitt Benckiser Deutschland GmbH, 69115 Heidelberg, Germany; (M.H.)
| | - Spasenija Bradic
- Reckitt Benckiser Deutschland GmbH, 69115 Heidelberg, Germany; (M.H.)
| | | | - Karel Kostev
- University Hospital, Philipps-University, 35043 Marburg, Germany
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Gunnarsson RK, Ebell M, Centor R, Little P, Verheij T, Lindbæk M, Sundvall PD. Best management of patients with an acute sore throat – a critical analysis of current evidence and a consensus of experts from different countries and traditions. Infect Dis (Lond) 2023; 55:384-395. [PMID: 36971650 DOI: 10.1080/23744235.2023.2191714] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND There is a very large body of publications discussing the management of patients with an acute sore throat. Advocates for a restrictive antibiotic policy and advocates for a more liberal use of antibiotics emphasise different and valid arguments and to date have not been able to unite in a consensus. Contradicting guidelines based on the same body of knowledge is not logical, may cause confusion and cause unwanted variation in clinical management. METHODS In multiple video meetings and email correspondence from March to November 2022 and finally in a workshop at the annual meeting for the North American Primary Care Group in November 2022, experts from different countries representing different traditions agreed on how the current evidence should be interpreted. RESULTS This critical analysis identifies that the problem can be resolved by introducing a new triage scheme considering both the acute risk for suppurative complications and sepsis as well as the long-term risk of developing rheumatic fever. CONCLUSIONS The new triage scheme may solve the long-standing problem of advocating for a restrictive use of antibiotics while also satisfying concerns that critically ill patients might be missed with severe consequences. We acknowledge that the perspective of this problem is vastly different between high- and low-income countries. Furthermore, we discuss the new trend which allows nurses and pharmacists to independently manage these patients and the increased need for safety netting required for such management.
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Rystedt K, Hedin K, Tyrstrup M, Skoog-Ståhlgren G, Edlund C, Giske CG, Gunnarsson R, Sundvall PD. Agreement between rapid antigen detection test and culture for group A streptococcus in patients recently treated for pharyngotonsillitis - a prospective observational study in primary care. Scand J Prim Health Care 2023; 41:91-97. [PMID: 36880344 PMCID: PMC10088972 DOI: 10.1080/02813432.2023.2182631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVE The aim was to compare rapid antigen detection test (RADT) and throat culture for group A streptococci (GAS) among patients recently treated with penicillin V for GAS pharyngotonsillitis. DESIGN AND SETTING The study was a secondary analysis within a randomized controlled trial comparing 5 versus 10 days of penicillin V for GAS pharyngotonsillitis. Patients were recruited at 17 primary health care centres in Sweden. SUBJECTS We included 316 patients ≥ 6 years of age, having 3-4 Centor criteria, a positive RADT and a positive throat culture for GAS at inclusion, and also having a RADT and throat culture for GAS taken at a follow-up visit within 21 days. MAIN OUTCOME MEASURES RADT and conventional throat culture for GAS. RESULTS This prospective study showed 91% agreement between RADT and culture at follow-up within 21 days. Only 3/316 participants had negative RADT with a positive throat culture for GAS at follow-up, and 27/316 patients with positive RADT had a negative culture for GAS. Log rank test did not reveal any difference in the decline over time of positive tests between RADT and throat culture (p = 0.24). Agreement between RADT and throat culture for GAS at the follow-up was not associated with treatment duration, number of days from inclusion until follow-up, throat symptoms at follow-up, gender, or age. CONCLUSION RADT and culture for GAS agreed to a high extent also after recent penicillin V treatment. RADT for GAS means a low risk for missing the presence of GAS.KEY POINTSTesting for group A streptococci (GAS) before antibiotic treatment can reduce antibiotic prescription for pharyngotonsillitis. It has been proposed that rapid antigen detection tests (RADT) for group A streptococci after recent penicillin V treatment may be falsely positive due to possible persisting antigens from non-viable bacteria.The decline of the presence of GAS was similar between RADT and conventional throat culture in patients who had recently completed penicillin V treatment for GAS pharyngotonsillitisRADT for GAS is useful in identifying the presence of GAS after recent penicillin V treatment.
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Affiliation(s)
- Karin Rystedt
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Hentorp Health Care Center, Gröna vagen, Skövde, Sweden
| | - Katarina Hedin
- Futurum, Region Jönköping County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Mia Tyrstrup
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden
| | - Gunilla Skoog-Ståhlgren
- Unit for Antibiotics and Infection Control, the Public Health Agency of Sweden, Solna, Sweden
| | - Charlotta Edlund
- Unit for Antibiotics and Infection Control, the Public Health Agency of Sweden, Solna, Sweden
| | - Christian G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ronny Gunnarsson
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Pär-Daniel Sundvall
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
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7
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Gunnarsson R, Orda U, Elliott B, Heal C, Del Mar C. What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies. BMJ Open 2022; 12:e059069. [PMID: 35487741 PMCID: PMC9058799 DOI: 10.1136/bmjopen-2021-059069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Identifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings. DESIGN We compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare. SETTING AND PARTICIPANTS The nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies. MAIN OUTCOME MEASURES The proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to. RESULTS In a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3-4 Centor scores (or 2-3 FeverPAIN scores or 3-4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%-15% of patients and prescribing antibiotics to only 3.5%-6.6%. CONCLUSIONS Patients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.
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Affiliation(s)
- Ronny Gunnarsson
- School of Public Health and Community Medicine - General Practice/Family Medicine, Göteborgs universitet Institutionen för medicin, Goteborg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Västra Götalandsregionen, Göteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Göteborg, Sweden
- The primary health care clinic for homeless people, Närhälsan, Region Västra Götaland, Göteborg, Sweden
| | - Ulrich Orda
- Mount Isa Hospital, North West Hospital and Health Service, Mount Isa, Queensland, Australia
| | | | - Clare Heal
- School of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Chris Del Mar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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Bird C, Winzor G, Lemon K, Moffat A, Newton T, Gray J. A Pragmatic Study to Evaluate the Use of a Rapid Diagnostic Test to Detect Group A Streptococcal Pharyngitis in Children With the Aim of Reducing Antibiotic Use in a UK Emergency Department. Pediatr Emerg Care 2021; 37:e249-e251. [PMID: 30045356 DOI: 10.1097/pec.0000000000001560] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Sore throat is a common presentation to the children's emergency department (ED), and many patients are likely prescribed antibiotics unnecessarily. We aimed to reduce antibiotic prescribing for sore throat in our UK ED through use of an established scoring system combined with a rapid diagnostic test (RDT) to detect group A streptococcal (GAS) pharyngitis. METHODS AB single-subject and diagnostic accuracy studies were used to measure both antibiotic prescribing rates over time and the performance of the McIsaac clinical score combined with RDT to screen for and treat GAS pharyngitis. All children between the age of 6 months and 16 years with symptoms of sore throat were eligible for inclusion. The study adhered to SQUIRE guidelines. RESULTS During 2014 and 2016, antibiotic prescribing rates for 210 children at baseline (median age, 3 years) and 395 children during the intervention (median age, 2 years) were assessed. The baseline prescribing rate was 79%, whereas rates after intervention were 24% and 27%, respectively. The RDT had an acceptable false-negative rate of 7.9%, poor sensitivity of 64.3%, and a negative predictive value of 92.1% when compared with conventional throat culture. A McIsaac score of 3 or more had good sensitivity (92.11%) but very low specificity (12.62%) for predicting GAS infection. CONCLUSIONS Despite poor RDT sensitivity and the McIsaac score's poor specificity in children, their use in combination decreased antibiotic prescribing rates in a children's ED setting.
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Affiliation(s)
- Chris Bird
- From the Emergency Department, John Radcliffe Hospital, Oxford
| | | | | | | | | | - Jim Gray
- Microbiology Department, Birmingham Children's Hospital, Birmingham, United Kingdom
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9
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Meskina ER, Stashko TV. [How to reduce the antibacterial load in the treatment of acute tonsillitis and pharyngitis? Possible tactics and practical approaches]. Vestn Otorinolaringol 2021; 85:90-99. [PMID: 33474925 DOI: 10.17116/otorino20208506190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute tonsillopharyngitis is one of the most frequent reasons for visiting a doctor and prescribing inappropriate antibiotic therapy (ABT). There are several reasons for this - from the difficulties of etiological diagnosis and the development of relapses and possible severe complications to the personal attitude of doctors and patients to the choice of treatment. At the same time, the issue of antibiotic resistance and other aspects associated with the prescription of ABT is one of the most important problems of modern healthcare worldwide. The purpose of this review is to demonstrate the best practical approaches to the choice of treatment tactics for acute tonsillitis (AT) in the treatment of children and adults, with an emphasis on reducing the load of ABT. The review examines the indications and disadvantages of clinical and laboratory diagnosis of AT. There are no highly sensitive clinical and laboratory instruments that differentiate viral and bacterial AT. Exudativeis AT in children is not an underlying symptom of streptococcal etiology. Despite the limitations, the modified Centor/McIsaac score ≥3 (taking into account age and the presence of respiratory symptoms) should be used as an indication for ABT in conjunction with a rapid streptotest and subsequent bacteriological culture for S. pyogenes if the screening test is negative. Additional examinations (determination of leukocytosis, CRP and procalcitonin test) are not required for most patients. ABT should not be given to low-risk patients for the treatment and prevention of rheumatic fever and acute glomerulonephritis. Prevention of purulent complications (paratonsillitis and retropharyngeal abscess, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis) is not a specific indication for ABT in AT and is not required in most patients. The strategy of «delayed antibiotic prescriptions» with monitoring the patient's condition for 2-3 days is appropriate and highly effective in doubtful cases. The drugs of choice for treatment of AT are amoxicillin and oral forms of I and II generation cephalosporins. Macrolides are not indicated as first-line treatment for AT. The course of ABT for streptococcal AT is 10 days, which reduces the risk of recurrent episode. Topical drugs can be the only means of etiopathogenetic treatment with viral AT, or additional for bacterial AT. Their use not only relieves sore throat, but also shortens the duration of the disease, and also improves the patients prognosis. Benzalkonium chloride + tyrothricin + benzocaine (Dorithyrcin) may be a rational drug of choice for topical therapy due to the available clinical evidence. There is a significant reserve for reducing the load of ABT during AT. Further clinical trials are needed to assess the efficacy of short courses of ABT in the treatment of AT in high-income countries and provide a basis for strong recommendations for topical drug use. This can reduce the frequency of ABT prescribing and increase the level of interaction between specialists and patients.
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Affiliation(s)
- E R Meskina
- Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia
| | - T V Stashko
- Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia
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Essack S, Bell J, Burgoyne D, Tongrod W, Duerden M, Sessa A, Altiner A, Shephard A. Point-of-Care Testing for Pharyngitis in the Pharmacy. Antibiotics (Basel) 2020; 9:E743. [PMID: 33126412 PMCID: PMC7693205 DOI: 10.3390/antibiotics9110743] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 02/06/2023] Open
Abstract
Pharyngitis (also known as sore throat) is a common, predominately viral, self-limiting condition which can be symptomatically managed without antibiotic treatment. Inappropriate antibiotic use for pharyngitis contributes to the development and spread of antibiotic resistance. However, a small proportion of sore throats caused by group A streptococcal (GAS) infection may benefit from the provision of antibiotics. Establishing the cause of infection is therefore an important step in effective antibiotic stewardship. Point-of-care (POC) tests, where results are available within minutes, can distinguish between viral and GAS pharyngitis and can therefore guide treatment in primary healthcare settings such as community pharmacies, which are often the first point of contact with the healthcare system. In this opinion article, the evidence for the use of POC testing in the community pharmacy has been discussed. Evidence suggests that pharmacy POC testing can promote appropriate antibiotic use and reduce the need for general practitioner consultations. Challenges to implementation include cost, training and 'who prescribes', with country and regional differences presenting a particular issue. Despite these challenges, POC testing for pharyngitis has become widely available in pharmacies in some countries and may represent a strategy to contain antibiotic resistance and contribute to antimicrobial stewardship.
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Affiliation(s)
- Sabiha Essack
- Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
| | - John Bell
- Graduate School of Health, University of Technology Sydney, Ultimo, NSW 2007, Australia;
| | - Douglas Burgoyne
- College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA;
| | - Wirat Tongrod
- Faculty of Pharmaceutical Sciences, Huachiew Chalermprakiet University, Samut Prakan 10540, Thailand;
| | - Martin Duerden
- School of Medicine, Centre for Medical Education, Cardiff University, Cardiff CF14 4XN, UK;
| | - Aurelio Sessa
- Italian College of General Practitioners and Primary Care (SIMG, Società Italiana di Medicina Generale delle Cure Primarie), 50142 Florence, Italy;
| | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, 18055 Rostock, Germany;
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11
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Hansen GT. Point-of-Care Testing in Microbiology: A Mechanism for Improving Patient Outcomes. Clin Chem 2020; 66:124-137. [PMID: 31811002 DOI: 10.1373/clinchem.2019.304782] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/15/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Increasingly, demands for improved health and quality of life conflict with the realities of delivering healthcare in an environment of higher expenditures, adherence to test utilization, and patient-centered experience. Patient-centered care is commonly identified as a goal of healthcare delivery, and yet healthcare systems struggle with delivery of care to patients, often failing to identify the seriously ill and capitalize on the predictive qualities of diagnostic testing. Point-of-care (POC) testing provides access to rapid diagnosis and predictive value key to realizing patient outcomes. An evaluation of cost-effective models and the clinical impact of POC testing for clinical microbiology is needed. CONTENT Accurate and rapid diagnostics have the potential to affect healthcare decisions to a degree well out of proportion to their cost. Contemporary healthcare models increasingly view POC testing as a mechanism for efficient deployment of healthcare. POC testing can deliver rapid diagnosis in environments where testing results can be used to direct management during patient visits and in areas where centralized laboratory testing may limit access to care. Nucleic acid assays, designed for POC testing, can match, or exceed, the sensitivity of conventional laboratory-based testing, eliminating the need for confirmation testing. Here, the goals of POC testing for microbiology, applications, and technologies, as well as outcomes and value propositions, are discussed. SUMMARY The combination of rapid reporting, an increasing array of organisms capable of causing disease, actionable resulting, and improved patient outcomes is key in the evolution of POC testing in clinical microbiology.
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Affiliation(s)
- Glen T Hansen
- Microbiology and Molecular Diagnostics, Hennepin County Medical Center, Department of Infectious Diseases, University of Minnesota School of Medicine, Minneapolis, MN.,Department of Pathology & Laboratory Medicine University of Minnesota, School of Medicine.,Department of Medicine, Infectious Diseases, University of Minnesota School of Medicine, Minneapolis, MN
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Cohen JF, Pauchard JY, Hjelm N, Cohen R, Chalumeau M. Efficacy and safety of rapid tests to guide antibiotic prescriptions for sore throat. Cochrane Database Syst Rev 2020; 6:CD012431. [PMID: 32497279 PMCID: PMC7271976 DOI: 10.1002/14651858.cd012431.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sore throat is a common condition caused by viruses or bacteria, and is a leading cause of antibiotic prescription in primary care. The most common bacterial species is group A streptococcus ('strep throat'). Between 50% to 70% of pharyngitis cases are treated with antibiotics, despite the majority of cases being viral in origin. One strategy to reduce antibiotics is to use rapid tests for group A streptococcus to guide antibiotic prescriptions. Rapid tests can be used alone or in combination with a clinical scoring system. OBJECTIVES To assess the efficacy and safety of strategies based on rapid tests to guide antibiotic prescriptions for sore throat in primary care settings. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and LILACS, as well as the trial registries ClinicalTrials.gov and the WHO ICTRP on 5 June 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing rapid tests with management based on clinical grounds to guide the prescription of antibiotics for people with a sore throat in ambulatory care settings. We included trials that randomised individuals, as well as cluster-RCTs in which individual practitioners (or practices) or emergency departments were randomised. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on the primary outcomes (number of participants provided with an antibiotic prescription; number of participants with an antibiotic dispensed) and secondary outcomes (duration of sore throat symptoms; duration of other symptoms; quality of life measures; number of participants with a complication attributed to the index infection; number of participants in need of re-consultation by the end of follow-up; number of participants in need of hospital admission by the end of follow-up; number of satisfied participants; number of participants with an adverse event attributed to the rapid test). We assessed the risk of bias of all included trials and used GRADE to assess the certainty of the evidence. We performed meta-analyses and sensitivity analyses when feasible. MAIN RESULTS We included five trials (2891 children and adult participants in total; 2545 participants after adjusting for clustering). Management in the intervention group was as follows: in three trials rapid tests were used in combination with a clinical scoring system; in one trial, some physicians were asked to use rapid tests alone, while others were asked to use rapid tests in combination with a clinical scoring system; in one trial, rapid tests were used alone. Based on data from five trials (2545 participants), a large reduction in prescribed antibiotics was found in the rapid test group (481/1197) versus management based on clinical grounds (865/1348), for a summary risk difference (RD) of -25%, 95% confidence interval (CI) -31% to -18%; I2 = 62%; moderate-certainty evidence. Estimates of effect on antibiotic prescription rates were stable in various sensitivity analyses. Based on data from two trials (900 people) originating from the same overarching study, the evidence suggests that rapid tests may not reduce dispensed antibiotic treatments: rapid test group (156/445) versus management based on clinical grounds (197/455); summary RD -7%, 95% CI -17% to 2%; I2 = 53%; low-certainty evidence. Four trials (2075 participants) reported data on the number of participants with a complication attributed to the index infection; the summary odds ratio (OR) was 0.85, 95% CI 0.03 to 26.65; P = 0.93; I2 = 62%; very low-certainty evidence, which means that people in the rapid testing group were less likely to develop complications of the index infection, but the evidence is very uncertain. Two trials (1161 participants) reported on the number of participants in need of re-consultation by the end of follow-up; the summary OR was 1.12, 95% CI 0.57 to 2.21; P = 0.74; I2 = 59%; low-certainty evidence, which means that participants in the rapid testing group were more likely to be in need of re-consultation by the end of the study follow-up, but the evidence is uncertain. Lack of data impeded assessment of other secondary outcomes (including safety outcomes) and of sources of heterogeneity. AUTHORS' CONCLUSIONS: Rapid testing to guide antibiotic treatment for sore throat in primary care probably reduces antibiotic prescription rates by 25% (absolute risk difference), but may have little or no impact on antibiotic dispensing. More studies are needed to assess the efficacy and safety of rapid test-guided antibiotic prescribing, notably to evaluate patient-centred outcomes and variability across subgroups (e.g. adults versus children).
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Affiliation(s)
- Jérémie F Cohen
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Hôpital Necker, Paris, France
- Université de Paris, CRESS, INSERM, Paris, France
| | - Jean-Yves Pauchard
- Département Médico-Chirurgical de Pédiatrie, Hôpital de l'Enfance de Lausanne, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Nils Hjelm
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes University, Paris, France
| | - Robert Cohen
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Saint-Maur-des-Fossés, France
| | - Martin Chalumeau
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Hôpital Necker, Paris, France
- Université de Paris, CRESS, INSERM, Paris, France
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Gunnarsson RK, Manchal N. Group C beta hemolytic Streptococci as a potential pathogen in patients presenting with an uncomplicated acute sore throat - a systematic literature review and meta-analysis. Scand J Prim Health Care 2020; 38:226-237. [PMID: 32362178 PMCID: PMC8570738 DOI: 10.1080/02813432.2020.1753374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Objective: The pathogenicity of beta-hemolytic Streptococcus group C (GCS) in patients attending for an uncomplicated acute sore throat is unknown and it was the objective to clarify this.Design: Systematic literature review with meta-analysis. Setting Medline and Scopus were searched from inception to February 2019, with searches of reference lists, Subjects case-control studies stating prevalence of GCS in patients as well as healthy controls presented for children and adults separately. Studies including patients already treated with antibiotics and studies focused on patients with HIV, malignancy or immunosuppression were not included. Main outcome measures Pooled prevalence of GCS was compared between patients and controls using chi-square and was further explored by calculating the positive etiologic predictive value (P-EPV) showing the post-test probability of a link between a sore throat and the bacterial finding. P-EPV for GCS was compared with that for group A Streptococci (GAS) using figures from the same publications and patients.Results: Eleven studies were included. The prevalence of GCS among patients versus controls was similar in children (3.15 versus 2.87%, p = .44) but for adults higher in patients (11%) than in controls (5.6%) (p < .0001). The P-EPV for finding GCS in children with a sore throat was 9.3% (0.0-41%). The corresponding P-EPV for GCS in adults with a sore throat was 53% (36-67%) while the corresponding P-EPV for GAS in adults was 94% (90-96%).Conclusions: GCS do not seem associated with the uncomplicated acute sore throat in children but there is support for an association in adults being weaker than for GAS. A possible consequence is to ignore GCS in otherwise healthy patients at their first visit for an uncomplicated sore throat. This would enable a stronger focus on the use of modern point of care tests (POCTs) to detect GAS.Key pointsThere is no current consensus on the pathogenicity of group C beta-hemolytic Streptococcus (GCS) in patients attending for an uncomplicated acute sore throat.This systematic literature review concludes it is unlikely that GCS is involved in the uncomplicated sore throat in otherwise healthy children.This meta-analysis found a moderate link between GCS and the uncomplicated sore throat in adults.The link in adults between GCS and the sore throat is much weaker than the corresponding link for group A beta-hemolytic Streptococcus.
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Affiliation(s)
- Ronny Kent Gunnarsson
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Region Västra Götaland, Research and Development Primary Health Care, Research and Development Center Södra Älvsborg, Boras, Sweden;
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden;
- CONTACT Ronny Kent Gunnarsson Primary Health Care, School of Public Health and community medicine, Institute of Medicine, the Sahlgrenska Academy, University of Gothenburg, Sweden
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Teratani Y, Hagiya H, Koyama T, Ohshima A, Zamami Y, Tatebe Y, Tasaka K, Shinomiya K, Kitamura Y, Sendo T, Hinotsu S, Kano MR. Association between rapid antigen detection tests and antibiotics for acute pharyngitis in Japan: A retrospective observational study. J Infect Chemother 2019; 25:267-272. [PMID: 30642770 DOI: 10.1016/j.jiac.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/11/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Yusuke Teratani
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan
| | - Hideharu Hagiya
- Division of Infection Control and Prevention, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka 5650871, Japan
| | - Toshihiro Koyama
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan; Education and Research Center for Clinical Pharmacy, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan.
| | - Ayako Ohshima
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan
| | - Yoshito Zamami
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, 3-18-15 Kuramoto, Tokushima, 7708503, Japan
| | - Yasuhisa Tatebe
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 7008558, Japan
| | - Ken Tasaka
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 7008558, Japan
| | - Kazuaki Shinomiya
- Education and Research Center for Clinical Pharmacy, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan; Department of Toji Pharmacy, SSmile Co., Ltd., 6-1-11 Syoko-center, Nishi-ku, Hiroshima, 7330833, Japan
| | - Yoshihisa Kitamura
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 7008558, Japan
| | - Toshiaki Sendo
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 7008558, Japan
| | - Shiro Hinotsu
- Department of Biostatistics and Clinical Epidemiology, Sapporo Medical University, South 1, West 17, Chuo-Ku, Sapporo, Hokkaido 0608556, Japan
| | - Mitsunobu R Kano
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan; Department of Pharmaceutical Biomedicine, Graduate School of Interdisciplinary Science and Engineering in Health Systems, Okayama University, 1-1-1 Tsushima-Naka, Kita-ku, Okayama, 7008530, Japan
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Vasudevan J, Mannu A, Ganavi G. McIsaac Modification of Centor Score in Diagnosis of Streptococcal Pharyngitis and Antibiotic Sensitivity Pattern of Beta-hemolytic Streptococci in Chennai, India. Indian Pediatr 2019. [DOI: 10.1007/s13312-019-1467-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lathia N, Sullivan K, Tam K, Brna M, MacNeil P, Saltmarche D, Agro K. Cost-minimization analysis of community pharmacy-based point-of-care testing for strep throat in 5 Canadian provinces. Can Pharm J (Ott) 2018; 151:322-331. [PMID: 31080532 DOI: 10.1177/1715163518790993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Strep throat point-of-care (POC) testing in community pharmacies will enable pharmacist-based care for this condition. Our objective was to conduct an economic evaluation of treating severe sore throat when this service was offered in pharmacies in 5 Canadian provinces. Methods We conducted 5 separate cost-minimization analyses for the provinces of Alberta, British Columbia, Nova Scotia, Ontario and Saskatchewan, from the public payer perspective, to estimate mean cost per patient of treating severe sore throat in 2 scenarios: 1) physician-based usual care in a family physician's office, a walk-in clinic or an emergency room (ER) and 2) a new scenario where patients received care described above or in a pharmacy offering strep throat POC testing. One-way sensitivity analyses were conducted to account for model uncertainty. Results Mean cost per patient for each pathway in the base-case analyses for the 5 provinces ranged from 1) $37.55 to $61.57 for family physician, 2) $37.55 to $61.57 for walk-in clinic, 3) $38.88 to $57.56 for ER and 4) $19.12 to $21.83 for pharmacy, representing savings ranging from $12.47 to $24.36 per patient for the new scenario. Approximate total cost savings range from $1.3 million to $2.6 million per year across the 5 provinces. All sensitivity analyses yielded cost savings for the new scenario. Discussion Across 5 provinces, strep throat POC testing in pharmacies was cost saving compared to physician-based care. Sensitivity analyses demonstrated the robustness of these results. Conclusions Funding strep throat POC testing in community pharmacies in these 5 provinces would lead to public health system cost savings and potentially improve patients' access to care for severe sore throat.
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Affiliation(s)
- Nina Lathia
- Loblaw Companies Limited (Sullivan, Tam, Brna, MacNeil, Saltmarche)
| | - Karen Sullivan
- Loblaw Companies Limited (Sullivan, Tam, Brna, MacNeil, Saltmarche)
| | - Kathy Tam
- Loblaw Companies Limited (Sullivan, Tam, Brna, MacNeil, Saltmarche)
| | - Margaret Brna
- Loblaw Companies Limited (Sullivan, Tam, Brna, MacNeil, Saltmarche)
| | - Paula MacNeil
- Loblaw Companies Limited (Sullivan, Tam, Brna, MacNeil, Saltmarche)
| | - Deb Saltmarche
- Loblaw Companies Limited (Sullivan, Tam, Brna, MacNeil, Saltmarche)
| | - Karen Agro
- Loblaw Companies Limited (Sullivan, Tam, Brna, MacNeil, Saltmarche)
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Papastergiou J, Trieu CR, Saltmarche D, Diamantouros A. Community pharmacist-directed point-of-care group A Streptococcus testing: Evaluation of a Canadian program. J Am Pharm Assoc (2003) 2018; 58:450-456. [PMID: 29681440 DOI: 10.1016/j.japh.2018.03.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 02/15/2018] [Accepted: 03/12/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Streptococcus pyogenes is an aerobic, gram-positive bacterium responsible for a wide variety of infections including common pharyngitis. Novel rapid antigen detection tests allow for diagnosis of group A Streptococcus (GAS) at the point of care. The objective of the study is to evaluate the effects and feasibility of community pharmacist-directed GAS testing. SETTING A retrospective analysis of aggregate billing data was conducted using descriptive statistics to evaluate the acceptance and feasibility of a community pharmacist-directed Streptococcus testing program at Shoppers Drug Mart pharmacies in the Canadian provinces of British Columbia, Alberta, and Nova Scotia. PRACTICE DESCRIPTION Pharmacists trained in sample collection offered the screening to patients with symptoms suggestive of Streptococcus species infection from November 28, 2015, to May 31, 2016. Throat swabs were collected and analyzed using the BD Veritor system for rapid detection of GAS. PRACTICE INNOVATION Pharmacist-directed point-of-care group A Streptococcus testing and management. EVALUATION Proportion of GAS-positive cases that resulted in the same day initiation of antibiotic therapy by pharmacists were collected. Patient satisfaction with the service was also evaluated. RESULTS Seven thousand and fifty patients were tested across 204 participating locations. The average age was 27.3 years, with children (age 5-14 years) representing 30.7% of the population; 25.5% of patients tested positive for GAS infection. Of the patients with positive results, antibiotic therapy was initiated within the same day in 68.7% of cases. In Alberta, where pharmacists have advanced prescribing authority, same-day initiation of therapy was 73.8% compared with a rate of 40.5% (P < 0.05) in the other jurisdictions. CONCLUSION These results highlight both the public readiness to access point-of-care services in community pharmacies and the ability of pharmacists to expedite management of patients with GAS. Pharmacy-based Streptococcus testing can facilitate prompt and appropriate access to antibiotic therapy, as was demonstrated in regions with advanced prescribing authority. Communication of recommendations to the physician remains a barrier.
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Nejashmikj VR, Stojkovska S, Topuzovska IK, Stavrikj K. Evidence Based Practice in Using Antibiotics for Acute Tonsillitis in Primary Care Practice. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2017; 38:63-68. [PMID: 28991775 DOI: 10.1515/prilozi-2017-0023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The increased use of antibiotics for acute tonsillitis is a public health problem. 80% of the antibiotic prescriptions for acute tonsillitis are done in the Primary Care practice (PCP). The inappropriate use of the antibiotic causes bacterial resistance and treatment failure. Only patients with acute tonsillitis caused by Group A beta-hemolytic streptococcus (GAS) have benefit of the antibiotic treatment, which is a predict cause in 5-20%. In order to assess the antibiotic prescribing for acute tonsillitis by the doctors in the PCP in Macedonia we use the data from the national project about antibiotic prescribing for acute respiratory tract infections which was conducted in November 2014 during a period of 4 weeks as part of the E-quality program sponsored by the IPCRG. 86 general practitioners from Macedonia have participated. The group of 1768 patients, from 4 months to 88 years of age, with diagnosis of acute tonsillitis was analyzed. The antibiotic prescriptions according to the Centor score criteria were compared to the Cochran's guidelines which are translated and recommended as national guidelines. 88.8% of the patients with acute tonsillitis were treated with antibiotics, of which 52.9% with Centor score 0 to 2 were treated inappropriate. The diagnosis is mostly made based on the clinical picture and the symptoms. Only (23.6%) of the patients were treated with antibiotics (Penicillin V and cephalexin) according to the guidelines. We concluded that there is a low adherence to the national guidelines. The clinical assessment is not accurate in determining the etiology. Also, there is a high nonadherence in prescribing the first choice of antibiotics. We emphasize the need to change the general practitioners' prescription behavior according to the guidelines.
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Kanji K, Saatci D, Rao GG, Khanna P, Bassett P, Williams B, Khan M. Antibiotics for tonsillitis: should the emergency department emulate general practice? J Clin Pathol 2016; 69:834-6. [DOI: 10.1136/jclinpath-2016-203808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 06/08/2016] [Indexed: 11/04/2022]
Abstract
ObjectivesTo determine whether antibiotics are prescribed appropriately for acute tonsillitis in an emergency department (ED).MethodsCross-sectional observational study in large district general hospital in London. Patients diagnosed and coded with ‘acute tonsillitis’ in the ED over a 3-month period in 2015. Medical records were reviewed for Centor criteria, which is a clinical scoring system to guide antibiotic prescribing in UK general practice. Drug charts were reviewed for the specific antibiotic(s) prescribed, and throat swab (TS) cultures were recorded.Results273/389 patients with tonsillitis were analysed—186 children, 87 adults. Exclusions were missing patient records (86), patients had/awaiting tonsillectomy (22), receiving antibiotics (6) and immunocompromised (2). Centor score (CS) was not recorded for any patient. Based on derived CS from documented signs/symptoms, antibiotics were prescribed inappropriately to 196/273 patients (80%; 95% CI 74% to 85%) including broad-spectrum antibiotics to 25%. These included co-amoxiclav (18%), amoxicillin (6%), azithromycin (0.5%) and ceftriaxone (0.5%). TSs were taken in 66/273(24%) patients; 10/66 were positive for group A streptococcus (GAS). However, 48/56 GAS negative patients were prescribed antibiotics.ConclusionsCS was not being used in the ED to guide antibiotic prescribing for acute tonsillitis. Antibiotic prescribing was based on clinical judgement. Based on derived CS (<3), 80% of patients were inappropriately prescribed antibiotics, particularly broad-spectrum antibiotics. Further studies need to assess use of CS to guide antibiotic prescription in ED. TSs were commonly performed in the ED but did not either improve diagnosis or guide antibiotic prescription.
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