The diagnosis of strep throat in adults in the emergency room

Analysis of Pediatric Acute Upper Airway Pathology During Local Wildfires and Increased PM 2.5 Burden

OBJECTIVE

As wildfires worldwide increase in severity and frequency, fine particulate matter (PM 2.5), generated as a component of wildfire smoke, increasingly impacts air quality. Children are particularly vulnerable to poor air quality in numerous ways, including inhalation of more air in proportion to their body size than adults. Though its adverse impacts on the lower airway are well demonstrated, the clinical effects of PM 2.5 on the pediatric upper airway are poorly understood and warrant investigation.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic medical center.

METHODS

From 2014 to 2023, patient presentations to a pediatric emergency department in Northern California during exposure periods of elevated PM 2.5 burden associated with nearby wildfires were identified. Patient diagnoses, presenting symptoms, and management were analyzed. Comparison group patients were evaluated during date-matched control periods with confirmed normal air quality. Chi-squared analyses determined significance.

RESULTS

During periods of increased wildfire-generated PM 2.5 burden, a significantly greater proportion of pediatric patients presented to the emergency department with upper airway pathology compared to matched control periods of healthy air quality. Further, a significantly greater proportion of patients were diagnosed with croup during wildfires. Of patients presenting with upper airway pathology, a significantly greater proportion experienced dysphonia during wildfires and had a negative strep test.

CONCLUSION

Wildfire-generated PM 2.5 may contribute to increased rates of croup presentations, and PM 2.5 may disproportionately affect the larynx in the pediatric upper airway. Larger population-based studies and preclinical models may clarify these clinical manifestations of a growing public health threat.

CLIA-Waived Group a Streptococcal Pharyngitis Test and Treat Programs in Community Pharmacies

Acute pharyngitis is mostly viral in origin, but antibiotics are commonly prescribed to cover group A streptococcus (GAS) which is the cause in 5%-30% of pharyngitis episodes. Patients are increasingly utilizing community pharmacy test and treat programs to diagnose and treat acute respiratory infections. There are several Clinical Laboratory Improvement Amendment (CLIA)-waived point-of-care tests (POCT) available to quickly identify GAS. The objective of this article is to explore the 11 antigen and two molecular CLIA-waived GAS POCTs currently available in the United States (U.S.) and the studies that assessed their use in pharmacy test and treat programs. Nine studies evaluated their use in community pharmacy test and treat programs and support their use, especially for decreasing unnecessary antibiotic prescriptions and providing access to care for patients without a primary care provider or after regular business hours. As medication dispensing margins continue to shrink, community pharmacists continue to seek additional ways to serve their patients and develop new revenue streams. Additionally, test and treat services are a means to improve access to care and promote outpatient antimicrobial stewardship. Recently, patients have expressed an increased willingness to receive care for various illnesses, including acute pharyngitis, at community pharmacies. Acute pharyngitis is well-suited for management in a community pharmacy since treatment recommendations are well established and straightforward. Overprescribing of antibiotics from traditional health care settings is higher than desired and pharmacy-based models have demonstrated the ability to decrease unwarranted antibiotic use. A pharmacy-based acute pharyngitis management model makes strong medical and business sense.

Evaluation of the Analytical Sensitivity of a Molecular Point-of-Care Assay as Compared to 3 Lateral Flow Assays for Group A Streptococcus

BACKGROUND

An accurate and timely diagnosis of pharyngitis caused by group A streptococcus (GAS) is essential for ensuring appropriate antibiotic therapy. Early detection through point-of-care (POC) testing is valuable in initiating effective treatment. This study aimed at evaluating the analytical sensitivity of the molecular ID NOW™ Strep A 2 POC test as compared to 3 POC lateral flow assays: BD Veritor™ Plus System, Sofia® Strep A+ Fluorescent Immunoassay, and Sekisui Diagnostic OSOM® Strep A test for GAS detection.

METHODS

Two Streptococcus pyogenes bacterial American Type Culture Collection (ATCC) isolates and one clinical isolate from a throat swab sample were used to evaluate the limit of detection (LoD) of each assay. Ten-fold serial dilutions of the isolates starting from 107 colony factor units (CFU)/mL were prepared, and each dilution was tested in triplicate for all 4 assays simultaneously. All tests were performed as per manufacturers' instructions. The LoD was defined as the last dilution that yielded positive results for all 3 replicates. CFU per swab was also calculated.

RESULTS

For the 3 isolates evaluated, LoDs of ID NOW Strep A 2 ranged from 3.125 × 103 to 2.5 × 104 CFU/mL; for Quidel Sofia the range was 1 × 106 to 1 × 107 CFU/mL; for BD Veritor the range was 1 × 107 to 1.5 × 107 CFU/mL; and for Sekisui OSOM the LoD was 1 × 107 CFU/mL for all 3 isolates.

CONCLUSIONS

Compared to antigen-based lateral flow assays (LFAs), the molecular ID Now Strep A 2 assay demonstrated a lower LoD, which translates into higher sensitivity. In a clinical setting, this could enable detection of samples with a lower bacterial load that could be missed by low-sensitivity LFAs.

Comparison of Initial Artificial Intelligence (AI) and Final Physician Recommendations in AI-Assisted Virtual Urgent Care Visits

BACKGROUND

Whether artificial intelligence (AI) assistance is associated with quality of care is uncertain.

OBJECTIVE

To compare initial AI recommendations with final recommendations of physicians who had access to the AI recommendations and may or may not have viewed them.

DESIGN

Retrospective cohort study.

SETTING

Cedars-Sinai Connect, an AI-assisted virtual urgent care clinic with intake questions via structured chat. When confidence is sufficient, AI presents diagnosis and management recommendations (prescriptions, laboratory tests, and referrals).

PATIENTS

461 physician-managed visits with AI recommendations of sufficient confidence and complete medical records for adults with respiratory, urinary, vaginal, eye, or dental symptoms from 12 June to 14 July 2024.

MEASUREMENTS

Concordance of diagnosis and management recommendations of initial AI recommendations and final physician recommendations. Physician adjudicators scored all nonconcordant and a sample of concordant recommendations as optimal, reasonable, inadequate, or potentially harmful.

RESULTS

Initial AI and final physician recommendations were concordant for 262 visits (56.8%). Among the 461 weighted visits, AI recommendations were more frequently rated as optimal (77.1% [95% CI, 72.7% to 80.9%]) compared with treating physician decisions (67.1% [CI, 62.9% to 71.1%]). Quality scores were equal in 67.9% (CI, 64.8% to 70.9%) of cases, better for AI in 20.8% (CI, 17.8% to 24.0%), and better for treating physicians in 11.3% (CI, 9.0% to 14.2%), respectively.

LIMITATIONS

Single-center retrospective study. Adjudicators were not blinded to the source of recommendations. It is unknown whether physicians viewed AI recommendations.

CONCLUSION

When AI and physician recommendations differed, AI recommendations were more often rated better quality. Findings suggest that AI performed better in identifying critical red flags and supporting guideline-adherent care, whereas physicians were better at adapting recommendations to changing information during consultations. Thus, AI may have a role in assisting physician decision making in virtual urgent care.

PRIMARY FUNDING SOURCE

K Health.

Inter-rater reliability of Centor score assessments between telemedicine and in-person examinations in patients with an acute sore throat

BACKGROUND

It is uncertain whether the Centor criteria can be reliably assessed during telemedicine encounters with patients seeking care for a sore throat. Acquiring this knowledge is important as sore throat is a common reason for telemedicine consultations.

OBJECTIVES: PRIMARY OBJECTIVE

To compare the inter-rater reliability of Centor score assessments via telemedicine versus in-person examinations. Secondary objectives: To investigate whether the interrater reliability varies when assessing patients who are children versus adults, and whether the telemedicine physician considered conditions for assessment as adequate.

METHODS

A cross-sectional study in which each patient initially underwent a telemedicine evaluation, followed by an in-person assessment conducted by an independent physician who was kept unaware of the outcome of the initial evaluation. Agreement between both assessments was measured using Cohen's kappa coefficient.

RESULTS

During 2020-2023 189 patients with a mean age of 31 years (SD 18) were included. Among them, 114 were female and 148 adults. Agreement was low with kappa between 0.47(95% CI 0.38 - 0.56) to 0.58 (95% CI 0.43-0.72) when comparing assessments of lymph nodes, tonsils and the total Centor score. Kappa was potentially acceptable for history of fever and absence of cough. Subgrouping participants into children and adults did not affect kappa of the total Centor score.

CONCLUSION

Telemedicine examination in patients with an acute sore throat is not reliable for assessing Centor criteria.

Snowball Group Usability Testing for Rapid and Iterative Multisite Tool Development: Method Development Study

Background

Usability testing is valuable for assessing a new tool or system's usefulness and ease-of-use. Several established methods of usability testing exist, including think-aloud testing. Although usability testing has been shown to be crucial for successful clinical decision support (CDS) tool development, it is often difficult to conduct across multisite development projects due to its time- and labor-intensiveness, cost, and the skills required to conduct the testing.

Objective

Our objective was to develop a new method of usability testing that would enable efficient acquisition and dissemination of results among multiple sites. We sought to address the existing barriers to successfully completing usability testing during CDS tool development.

Methods

We combined individual think-aloud testing and focus groups into one session and performed sessions serially across 4 sites (snowball group usability testing) to assess the usability of two CDS tools designed for use by nurses in primary and urgent care settings. We recorded each session and took notes in a standardized format. Each site shared feedback from their individual sessions with the other sites in the study so that they could incorporate that feedback into their tools prior to their own testing sessions.

Results

The group testing and snowballing components of our new usability testing method proved to be highly beneficial. We identified 3 main benefits of snowball group usability testing. First, by interviewing several participants in a single session rather than individuals over the course of weeks, each site was able to quickly obtain their usability feedback. Second, combining the individualized think-aloud component with a focus group component in the same session helped study teams to more easily notice similarities in feedback among participants and to discuss and act upon suggestions efficiently. Third, conducting usability testing in series across sites allowed study teams to incorporate feedback based on previous sites' sessions prior to conducting their own testing.

Conclusions

Snowball group usability testing provides an efficient method of obtaining multisite feedback on newly developed tools and systems, while addressing barriers typically associated with traditional usability testing methods. This method can be applied to test a wide variety of tools, including CDS tools, prior to launch so that they can be efficiently optimized.

Association of adenoid hypertrophy and clinical parameters with preoperative polygraphy in pediatric patients undergoing adenoidectomy

BACKGROUND

Adenotonsillar hypertrophy is the most frequent cause for obstructive sleep apnea (OSAS) in children. In patients with small tonsils and where adenoid size cannot be assessed, the indication for adenoidectomy often relies on clinical symptoms. However, data on the association of clinical parameters and adenoid hypertrophy with OSAS severity in children undergoing an adenoidectomy is sparse.

AIM

To investigate the correlation of patient characteristics, adenoid hypertrophy, and clinical symptoms with OSAS severity in pediatric patients indicated for an adenoidectomy.

METHODS

We performed a retrospective chart review of all pediatric patients at our tertiary referral center between 2018 and 2023 who underwent polygraphy (PG) for OSAS diagnostics. Adenoid hypertrophy was assessed as adenoid-choanal ratio (AC-ratio) via nasal endoscopy and clinical symptom score (CS) via physical examination and parental survey. We included all symptomatic children with mild to severe OSAS (apnea-hypopnea index (AHI) ≥ 1). Exclusion criteria were obesity according to BMI and/or the presence of systemic diseases. The patients were divided according to age in a preschool and school cohort. Patient characteristics and PG data were compared between both groups. Linear regression analysis was used to investigate the association of AC-ratio, CS and BMI with the AHI.

RESULTS

A total of 121 patients were identified of which 81 were included in our study, resulting in 42 and 39 patients from 3-5 and 6-14 years of age, respectively. We observed a significant correlation between CS and BMI (p = 0.026) and the CS and AC-ratio (p < 0.001). Univariable regression analysis showed significant association of the AC-ratio and CS with AHI-score for the total (p < 0.001), the preschool (p < 0.001), and the school cohort (p < 0.001). In multivariable regression analysis, the significant association of AC-ratio and CS remained in the total (p = 0.014; p < 0.001), and the preschool cohort (p = 0.029; p = 0.002). However, only the CS remained as positive predictor in the school cohort.

CONCLUSION

AC-ratio and clinical symptoms seem to be reliable predictors for OSAS severity in patients between 3-14 years of age. Moreover, only clinical symptoms were associated with OSAS severity in schoolchildren. Future investigation should contribute to the validation of our results.

The relationship between group A streptococcus test positivity and clinical findings in tonsillopharyngitis in children: systematic review and meta-analysis

PURPOSE

This study aimed to present an evidence-based conclusion through a systematic meta-analysis to distinguish clinical signs and symptoms associated with the presence of group A beta-hemolytic streptococcus, as confirmed by throat culture or rapid test, from those in cases without culture confirmation.

METHODS

The study protocol has been published in PROSPERO (CRD42023450854). Studies published between January 1, 2013 and August 15, 2023 were scanned in seven databases. The methodological quality of the articles was assessed using The Joanna Briggs Institution (JBI) Cross-Sectional Studies and Cohort Studies checklist. Effect size calculations were made using fixed effects and random effects models.

RESULTS

A total of 22 articles were included in the systematic review, with 14 included in the meta-analysis. The prevalence of streptococcal pharyngitis in these studies ranged from 7.3 to 44.1%. According to the meta-analysis results, a significant association was observed between GAS test positivity and the presence of tonsillar exudate, palatal petechiae, tonsillar hypertrophy, dysphagia, fever, and cervical lymphadenopathy (p < 0.05). No significant relationship was found between GAS test positivity and symptoms such as headache, sore throat, cough, absence of cough, hoarseness, scarlatiniform rash, tonsillar erythema, vomiting, rhinorrhea, and abdominal pain (p > 0.05).

CONCLUSION

The findings of the meta-analysis suggest that, in addition to the Centor criteria, palatal petechiae, dysphagia, and tonsillar hypertrophy are noteworthy indicators of GAS infection. Contrary to previous studies, our meta-analysis indicates that symptoms such as headache, sore throat, cough, absence of cough, hoarseness, scarlatiniform rash, tonsillar erythema, vomiting, rhinorrhea, and abdominal pain may not be associated with streptococcal infection. Further research is needed to elucidate these findings.

Inappropriate antibiotic prescription for acute tonsillitis in low- and middle-income countries (LMICs): a systematic review and meta-analysis protocol

INTRODUCTION

Tonsillitis is a self-limiting inflammatory process of the tonsils. In high-income countries, guidelines have been developed to decide if a patient needs an antibiotic or not. These guidelines help to reduce unnecessary antibiotic prescriptions and prevent the development of antimicrobial resistance (AMR). In low- and middle-income countries (LMICs), medical practitioners have the tendency to prescribe antibiotics in all cases of tonsillitis; there is an overprescription of antibiotics. These prescriptions are probably unjustified and seem to be responsible for the increased AMR seen in developing countries. The aim of this review will be to estimate the proportion of unjustified antibiotic prescriptions in LMICs.

METHODS AND ANALYSIS

We will conduct a systematic review of all observational studies on the diagnosis and treatment of tonsillitis in LMICs. The selected database will include PubMed, Web of Sciences Global Index Medicus and the Grey literature. The search will include studies published from January 2012 until December 2024. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and bias will be assessed by a Risk of Bias Assessment Tool for observational studies by Hoy et al. A meta-analysis will be conducted for homogeneous studies, eventually using the random effect model. Subgroup analysis will include a period of study, study quality, countries and/or subregions of LMICs involved, study setting, age of participants, tools and definition used.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as primary data will not be collected. The results will be disseminated through peer-reviewed publications and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD 42022384957.

Duration of severe and moderate symptoms in pharyngitis by cause

OBJECTIVE

This study aimed to assess the cause of acute pharyngitis and determine the duration of severe and moderate symptoms based on the aetiology.

DESIGN

Prospective observational study. SITE: One urban health care centre.

PARTICIPANTS

Patients aged 15 or older with acute pharyngitis were included.

INTERVENTIONS

Bacterial identification was carried out in the microbiology lab using MALDI-TOF in two throat samples. Patients received a symptom diary to return after one week.

MAIN MEASUREMENTS

Number of days with severe symptoms, scoring 5 or more in any of the symptoms included in the symptom diary, and moderate symptoms, scoring 3 or more.

RESULTS

Among the 149 patients recruited, beta-haemolytic streptococcus group A (GABHS) was the most common aetiology. Symptoms and signs alone as well as the mean Centor score cannot distinguish between GABHS and other bacterial causes in patients with acute pharyngitis. However, there was a trend indicating that infections caused by Streptococcus dysgalactiae and Streptococcus agalactiae presented more severe symptoms, whereas infections attributed to the Streptococcus anginosus group, Fusobacterium spp., and those where oropharyngeal microbiota was isolated tended to have milder symptoms. S. dysgalactiae infections showed a trend towards longer severe and moderate symptom duration.

CONCLUSION

GABHS was the most prevalent, but group C streptococcus caused more severe and prolonged symptoms.

Review: Known, Emerging, and Remerging Pharyngitis Pathogens

Pharyngitis is an inflammatory condition of the pharynx and/or tonsils commonly seen in both children and adults. Viruses and bacteria represent the most common encountered etiologic agents-yeast/fungi and parasites are infrequently implicated. Some of these are predominantly observed in unique populations (eg, immunocompromised or unvaccinated individuals). This article (part 1 of 3) summarizes the impact of acute pharyngitis on the health care system and reviews the etiologic agents of acute pharyngitis, including both emerging and reemerging pathogens that health care providers should consider when evaluating their patients. Finally, it sets the stage for parts 2 and 3, which discuss the current and evolving state of diagnostic testing for acute pharyngitis.

Novel Diagnostic Approach for Acute Pharyngitis: Combining Machine Learning With Thermal Imaging

We evaluated the effect of infrared thermography (IRT) on the clinical assessment of bacterial and viral pharyngitis and its impact on the predictive value of the McIsaac score algorithm for streptococcal pharyngitis in children. We also investigated if IRT could distinguish between bacterial and viral pharyngitis. The study included children aged 2-17 years presenting with sore throat and fever over 38°C from November 1, 2021, to April 30, 2022. Of the 76 assessed children, 16 were excluded due to missing data or technical issues, leaving 60 children (32 males, 28 females) divided into three groups: Group A with streptococcal pharyngitis (N = 30), viral pharyngitis (N = 16), and healthy controls (N = 14). McIsaac score and IRT imaging showed a 90% positive predictive value for streptococcal pharyngitis. While IRT alone could not distinguish between bacterial and viral infections, it significantly increased the predictive value when combined with the McIsaac score.

Fifteen-minute consultation: Group A streptococcal pharyngitis, diagnosis and treatment in children

Group A streptococcus (GAS) is the most common bacterial cause of pharyngitis in children. GAS causes significant suppurative and non-suppurative complications including invasive GAS disease and acute rheumatic fever. This article describes the current epidemiology and clinical presentation of GAS pharyngitis and explores how diagnostic and treatment decisions differ globally. Several key decision support tools are discussed including international guidelines, clinical decision scores and laboratory tests along with the evidence for treatment choice and duration. With recent international reports describing an increase in GAS infections, clinicians should be familiar with their local GAS pharyngitis guidelines and the rationale for diagnosis and treatment of this common childhood illness.

[Clinical diagnosis of group A streptococcal pharyngitis and progress in the application of scoring systems]

Pharyngitis can be caused by various pathogens, including viruses and bacteria. Group A streptococcus (GAS) is the most common bacterial cause of pharyngitis. However, distinguishing GAS pharyngitis from other types of upper respiratory tract infections is challenging in clinical settings. This often leads to empirical treatments and, consequently, the overuse of antimicrobial drugs. With the advancement of antimicrobial drug management and healthcare payment reform initiatives in China, reducing unnecessary testing and prescriptions of antimicrobial drugs is imperative. To promote standardized diagnosis and treatment of GAS pharyngitis, this article reviews various international guidelines on the clinical diagnosis and differential diagnosis of GAS pharyngitis, particularly focusing on clinical scoring systems guiding laboratory testing and antimicrobial treatment decisions for GAS pharyngitis and their application recommendations, providing a reference for domestic researchers and clinical practitioners.

Is Streptococcus pyogenes a pathogen or passenger in uncomplicated acute sore throat? A systematic review and meta-analysis

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.

Explainable AI decision support improves accuracy during telehealth strep throat screening

BACKGROUND

Artificial intelligence-based (AI) clinical decision support systems (CDSS) using unconventional data, like smartphone-acquired images, promise transformational opportunities for telehealth; including remote diagnosis. Although such solutions' potential remains largely untapped, providers' trust and understanding are vital for effective adoption. This study examines how different human-AI interaction paradigms affect clinicians' responses to an emerging AI CDSS for streptococcal pharyngitis (strep throat) detection from smartphone throat images.

METHODS

In a randomized experiment, we tested explainable AI strategies using three AI-based CDSS prototypes for strep throat prediction. Participants received clinical vignettes via an online survey to predict the disease state and offer clinical recommendations. The first set included a validated CDSS prediction (Modified Centor Score) and the second introduced an explainable AI prototype randomly. We used linear models to assess explainable AI's effect on clinicians' accuracy, confirmatory testing rates, and perceived trust and understanding of the CDSS.

RESULTS

The study, involving 121 telehealth providers, shows that compared to using the Centor Score, AI-based CDSS can improve clinicians' predictions. Despite higher agreement with AI, participants report lower trust in its advice than in the Centor Score, leading to more requests for in-person confirmatory testing.

CONCLUSIONS

Effectively integrating AI is crucial in the telehealth-based diagnosis of infectious diseases, given the implications of antibiotic over-prescriptions. We demonstrate that AI-based CDSS can improve the accuracy of remote strep throat screening yet underscores the necessity to enhance human-machine collaboration, particularly in trust and intelligibility. This ensures providers and patients can capitalize on AI interventions and smartphones for virtual healthcare.

Symptoms predictive of Fusobacterium necrophorum pharyngotonsillitis - an observational study of cases presenting to hospitals in Southern Sweden

OBJECTIVES

Fusobacterium necrophorum is a common cause of pharyngotonsillitis. However, no guidelines exist on when to diagnose or treat it. We aimed to investigate associations between clinical criteria and F. necrophorum-positivity in pharyngotonsillitis and assess the predictive potential of a simple scoring system.

METHODS

Pharyngotonsillitis patients who were tested for F. necrophorum (PCR) and presented to hospitals in the Skåne Region, Sweden, between 2013-2020 were eligible. Data were retrieved from electronic chart reviews and registries. By logistic regression we investigated associations between F. necrophorum-positivity and pre-specified criteria: age 13-30 years, symptom duration ≤ 3 days, absence of viral symptoms (e.g. cough, coryza), fever, tonsillar swelling/exudate, lymphadenopathy and CRP ≥ 50 mg/L. In secondary analyses, associated variables were weighted by strength of association into a score and its predictive accuracy of F. necrophorum was assessed.

RESULTS

Among 561 cases included, 184 (33%) had F. necrophorum, which was associated with the following criteria: age 13-30, symptom duration ≤ 3 days, absence of viral symptoms, tonsillar swelling/exudate and CRP ≥ 50 mg/L. Age 13-30 had the strongest association (OR5.7 95%CI 3.7-8.8). After weighting, these five variables had a sensitivity and specificity of 68% and 71% respectively to predict F. necrophorum-positivity at the proposed cut-off.

CONCLUSION

Our results suggest that F. necrophorum cases presenting to hospitals might be better distinguished from other pharyngotonsillitis cases by a simple scoring system presented, with age 13-30 being the strongest predictor for F. necrophorum. Prospective studies, involving primary care settings, are needed to evaluate generalisability of findings beyond cases presenting to hospitals.

Does the Addition of Point-of-Care Testing Alter Antibiotic Prescribing Decisions When Patients Present with Acute Sore Throat to Primary Care? A Prospective Test of Change

Accurate clinical diagnosis of patients presenting to primary care settings with acute sore throat remains challenging, often resulting in the over-prescribing of antibiotics. Using point-of-care tests (POCTs) to differentiate between respiratory infections is well-accepted, yet evidence on the application within primary care is sparse. We assessed the application of testing patients (n = 160) from three family practices with suspected Streptococcal infections using rapid molecular tests (ID NOW Strep A2, Abbott). In addition to comparing clinical evaluation and prescription rates with either usual care or testing, patients and staff completed a questionnaire about their experience of molecular POCT in primary care. The immediate availability of the result was important to patients (100%), and staff (≈90%) stated that molecular testing improved the quality of care. Interestingly, only 22.73% of patients with a Centor score > 2 tested positive for Strep A and, overall, less than 50% of Centor scores 3 and 4 tested positive for Strep A with the ID NOW testing platform. The addition of rapid molecular POCTs to clinical assessment resulted in a 55-65% reduction in immediate and deferred antibiotic prescriptions. The intervention was popular with patients and medical staff but was associated with increased cost and a longer appointment length.

Barriers to Implementing Registered Nurse-Driven Clinical Decision Support for Antibiotic Stewardship: Retrospective Case Study

BACKGROUND

Up to 50% of antibiotic prescriptions for upper respiratory infections (URIs) are inappropriate. Clinical decision support (CDS) systems to mitigate unnecessary antibiotic prescriptions have been implemented into electronic health records, but their use by providers has been limited.

OBJECTIVE

As a delegation protocol, we adapted a validated electronic health record-integrated clinical prediction rule (iCPR) CDS-based intervention for registered nurses (RNs), consisting of triage to identify patients with low-acuity URI followed by CDS-guided RN visits. It was implemented in February 2022 as a randomized controlled stepped-wedge trial in 43 primary and urgent care practices within 4 academic health systems in New York, Wisconsin, and Utah. While issues were pragmatically addressed as they arose, a systematic assessment of the barriers to implementation is needed to better understand and address these barriers.

METHODS

We performed a retrospective case study, collecting quantitative and qualitative data regarding clinical workflows and triage-template use from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR intervention. Guided by the updated CFIR (Consolidated Framework for Implementation Research), we characterized the initial barriers to implementing a URI iCPR intervention for RNs in ambulatory care. CFIR constructs were coded as missing, neutral, weak, or strong implementation factors.

RESULTS

Barriers were identified within all implementation domains. The strongest barriers were found in the outer setting, with those factors trickling down to impact the inner setting. Local conditions driven by COVID-19 served as one of the strongest barriers, impacting attitudes among practice staff and ultimately contributing to a work infrastructure characterized by staff changes, RN shortages and turnover, and competing responsibilities. Policies and laws regarding scope of practice of RNs varied by state and institutional application of those laws, with some allowing more clinical autonomy for RNs. This necessitated different study procedures at each study site to meet practice requirements, increasing innovation complexity. Similarly, institutional policies led to varying levels of compatibility with existing triage, rooming, and documentation workflows. These workflow conflicts were compounded by limited available resources, as well as an implementation climate of optional participation, few participation incentives, and thus low relative priority compared to other clinical duties.

CONCLUSIONS

Both between and within health care systems, significant variability existed in workflows for patient intake and triage. Even in a relatively straightforward clinical workflow, workflow and cultural differences appreciably impacted intervention adoption. Takeaways from this study can be applied to other RN delegation protocol implementations of new and innovative CDS tools within existing workflows to support integration and improve uptake. When implementing a system-wide clinical care intervention, considerations must be made for variability in culture and workflows at the state, health system, practice, and individual levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04255303; https://clinicaltrials.gov/ct2/show/NCT04255303.

Group A Streptococcus pharyngitis in Children: New Perspectives on Rapid Diagnostic Testing and Antimicrobial Stewardship

The most common cause of bacterial pharyngitis is Group A Streptococcus (GAS). Accurate diagnosis of GAS pharyngitis is crucial to identify children who would benefit from antibiotic treatment. Rapid diagnosis has the potential to reduce antibiotic overuse. Current national guidelines differ in their recommendations for GAS testing. While rapid antigen detection tests (RADTs) are widely used, their sensitivity is considered too low for stand-alone testing by several expert bodies. Newer molecular tests using nucleic acid amplification show higher accuracy and fast results, but their cost, complexity, and very high sensitivity may limit widespread adoption. This review provides up-to-date evidence regarding rapid diagnostic testing and antimicrobial stewardship in children with sore throat. We discuss discrepancies across GAS testing guidelines at the international level, patient selection for testing for GAS, rapid test accuracy, and the potential role of rapid GAS tests to promote antibiotic stewardship, with emphasis on emerging rapid molecular tests.

Systematic review and meta-analysis of the accuracy of McIsaac and Centor score in patients presenting to secondary care with pharyngitis

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.

Diagnostic performance of clinical prediction rules to detect group A beta-haemolytic streptococci in people with acute pharyngitis: a systematic review

OBJECTIVE

To assess and compare the diagnostic performance of Clinical Prediction Rules (CPRs) developed to detect group A Beta-haemolytic streptococci in people with acute pharyngitis (or sore throat).

STUDY DESIGN

A systematic review.

METHODS

We searched PubMed, Embase and Web of Science (inception-September 2022) for studies deriving and/or validating CPRs comprised of ≥2 predictors from an individual's history or physical examination. Two authors independently screened articles, extracted data and assessed risk of bias in included studies. A meta-analysis was not possible due to heterogeneity. Instead we compared the performance of CPRs when they were validated in the same study population (head-to-head comparisons). We used a modified grading of recommendations, assessment, development, and evaluations (GRADE) approach to assess certainty of the evidence.

RESULTS

We included 63 studies, all judged at high risk of bias. Of 24 derived CPRs, 7 were externally validated (in 46 external validations). Five validation studies provided data for head-to-head comparison of four pairs of CPRs. Very low certainty evidence favoured the Centor CPR over the McIsaac (2 studies) and FeverPain CPRs (1 study) and found the Centor CPR was equivalent to the Walsh CPR (1 study). The AbuReesh and Steinhoff 2005 CPRs had a similar poor discriminative ability (1 study). Within and between study comparisons suggested the performance of the Centor CPR may be better in adults (>18 years).

CONCLUSION

Very low certainty evidence suggests a better performance of the Centor CPR. When deciding about antibiotic prescribing for pharyngitis patients, involving patients in a shared decision making discussion about the likely benefits and harms, including antibiotic resistance, is recommended. Further research of higher rigour, which compares CPRs across multiple settings, is needed.

Diagnostic and Therapeutic Challenges in a Military Recruit Training Center of the Hellenic Navy: A Retrospective Analysis of the Poros Registry Serving as a Quality Improvement Project for Medical Officers

INTRODUCTION

Basic military training (BMT) has been associated with increased morbidity burden. Nevertheless, the exact epidemiology of the encountered cases in the BMT of Greek recruits has never been assessed. The aim of this quality improvement project was to investigate for the first time the clinical patterns, rates, and severity of symptoms leading recruits to visit the infirmary of a recruit training center and use this knowledge to provide a practical guidance for the physicians in charge.

MATERIALS AND METHODS

All medical cases which were consecutively examined for the time range from November 2021 to September 2022 at the infirmary of the Hellenic Naval recruit training center in Poros, Greece, were retrospectively analyzed. Logistic regression analyses were performed to identify independent predictors of "severe clinical status" (i.e., overnight sick bay confinement and/or transfer to a tertiary hospital within 24 h) and absence from BMT for at least 1 day.

RESULTS

A total of 2,623 medical cases were examined during four recruit seasons from November 2021 to September 2022. Upper respiratory tract infections (URTIs) and musculoskeletal injuries were the most frequent reasons for a recruit's visit to the infirmary (33.9% and 30.2%, respectively). 6.7% of the total cases were identified as having "severe clinical status." Specifically, in psychiatric, urological, and cardiovascular cases, febrile events were all independently associated with increased risk of "severe clinical status." There was a positive association between training week and absence from BMT, while febrile events and spring recruit season were also independently linked with increased probability of absence from BMT for at least 1 day.

CONCLUSIONS

URTIs and musculoskeletal complaints were the primary reasons for recruits' presentation at the infirmary of a Greek recruit training center, leading to severe rates of attrition. Further registries and quality improvement projects are warranted to reach specific conclusions and reduce BMT-related morbidity and its subsequent implications.

The use and usefulness of point-of-care tests in patients with pharyngotonsillitis - an observational study in primary health care

BACKGROUND

Rapid antigen detection tests (RADT) for Group A streptococci (GAS) and point-of-care tests for C-reactive protein (CRP) are commonly used in patients with pharyngotonsillitis in Sweden and Denmark although CRP testing is not supported by guidelines. We aimed to describe (1) the proportion of patients tested with RADT and/or CRP, (2) the relation between test results and antibiotic prescribing, and (3) the association between CRP level and microbial aetiology.

METHODS

We used a post-hoc-analysis of data collected in primary health care in a prospective aetiological study of 220 patients 15-45 years old diagnosed with pharyngotonsillitis. The outcomes of RADTs and CRP tests were related to antibiotic prescribing and microbial aetiology.

RESULTS

A RADT was used in 94% of the patients. A CRP test was used in 50% of the patients but more commonly in those with a negative RADT (59%) than in those with a positive RADT (38%) (p = 0.005). Most (74%) CRP tests were used in patients with a negative RADT. Antibiotic prescribing differed greatly between patients with a positive RADT (96%) and patients with a negative RADT (17%) (p < 0.001). In patients with a negative RADT, there was a positive association between CRP value and antibiotic prescribing (OR 1.05; 95% CI 1.02-1.07; p < 0.001). Patients with CRP values ≤ 30 mg/l were seldomly prescribed antibiotics. Patients with GAS in culture had the highest median CRP (46 mg/l), which was higher than in patients without GAS (8 mg/l; p < 0.001). However, the positive predictive value for GAS never exceeded 0.60 (95% CI 0.31-0.83) at the investigated CRP levels.

CONCLUSIONS

The widespread use of tests is a major deviation from national guidelines. Most CRP tests were used in patients with a negative RADT, suggesting a belief in the added value of a CRP test, and the CRP result seemed to influence antibiotic prescribing. However, as an aetiological test, CRP is not useful for predicting GAS.

Group A β-hemolytic Streptococcal Pharyngitis: An Updated Review

BACKGROUND

Group A ß-hemolytic Streptococcus (GABHS) is the leading bacterial cause of acute pharyngitis in children and adolescents worldwide.

OBJECTIVE

This article aims to familiarize clinicians with the clinical manifestations, evaluation, diagnosis, and management of GABHS pharyngitis.

METHODS

A search was conducted in December 2022 in PubMed Clinical Queries using the key term "group A β-hemolytic streptococcal pharyngitis". This review covers mainly literature published in the previous ten years.

RESULTS

Children with GABHS pharyngitis typically present with an abrupt onset of fever, intense pain in the throat, pain on swallowing, an inflamed pharynx, enlarged and erythematous tonsils, a red and swollen uvula, enlarged tender anterior cervical lymph nodes. As clinical manifestations may not be specific, even experienced clinicians may have difficulties diagnosing GABHS pharyngitis solely based on epidemiologic or clinical grounds alone. Patients suspected of having GABHS pharyngitis should be confirmed by microbiologic testing (e.g., culture, rapid antigen detection test, molecular point-of-care test) of a throat swab specimen prior to the initiation of antimicrobial therapy. Microbiologic testing is generally unnecessary in patients with pharyngitis whose clinical and epidemiologic findings do not suggest GABHS. Clinical score systems such as the Centor score and McIssac score have been developed to help clinicians decide which patients should undergo diagnostic testing and reduce the unnecessary use of antimicrobials. Antimicrobial therapy should be initiated without delay once the diagnosis is confirmed. Oral penicillin V and amoxicillin remain the drugs of choice. For patients who have a non-anaphylactic allergy to penicillin, oral cephalosporin is an acceptable alternative. For patients with a history of immediate, anaphylactic-type hypersensitivity to penicillin, oral clindamycin, clarithromycin, and azithromycin are acceptable alternatives.

CONCLUSION

Early diagnosis and antimicrobial treatment are recommended to prevent suppurative complications (e.g., cervical lymphadenitis, peritonsillar abscess) and non-suppurative complications (particularly rheumatic fever) as well as to reduce the severity of symptoms, to shorten the duration of the illness and to reduce disease transmission.

A Longitudinal Study of Group A Streptococcal Colonization and Pharyngitis in US Children

BACKGROUND

Group A streptococci (GAS) are a major cause of pharyngitis in children. Recently, there were severe GAS outbreaks. The aims of this study were to assess pharyngeal colonization prevalence in healthy children, to assess different diagnostic definitions for GAS pharyngitis and to estimate incidence rates for these infections.

METHODS

A 2-year longitudinal study was conducted in healthy children in the United States. Pharyngeal swabs were cultured every 3 months for GAS colonization. Serum antistreptolysin O, antideoxyribonuclease B (DNaseB) and antistreptococcal C5a peptidase (SCP) antibody titers were assessed at baseline. When participants developed a sore throat, pharyngeal swabs were collected for rapid antigen detection test (RADT) and culture, and antibody titers were determined in serum samples. A range of case definitions were used for GAS pharyngitis.

RESULTS

A total of 422 children 3-12 years old were enrolled (140, 141 and 141 were 3-5, 6-9 and 10-12 years of age, respectively). The overall prevalence of GAS colonization during the study was 48%. Baseline antistreptolysin O, anti-DNaseB and anti-SCP antibody titers were higher for children older than 5 years. The incidence of GAS pharyngitis per 100 person-years was 15.9 for RADT/culture-proven and 4.6 for serologically confirmed pharyngitis.

CONCLUSIONS

GAS throat colonization and pharyngitis were frequent in children 3-12 years old. The case definition employed impacted the measured incidence of GAS pharyngitis, with higher rates detected using RADT/culture-based definitions. These data suggest that case definition is important and that young children are exposed to GAS, which may inform plans for vaccine development and implementation.

Medicalising diagnoses and treatment preferences: a retrospective cohort study of throat-related consultations in electronic primary care records

BACKGROUND

Rather than first diagnosing and then deciding on treatment, GPs may intuitively decide on treatment and justify this through choice of diagnosis.

AIM

To investigate the relationship between choice of a medicalising diagnosis and antibiotic treatment for throat-related consultations.

DESIGN & SETTING

A retrospective cohort study in a large database of UK electronic primary care records between 1 January 2010 and 1 January 2020.

METHOD

All first throat-related consultations were included, categorised as either pharyngitis/tonsillitis or sore throat. The outcome was any antibiotic prescription on the consultation date. GP-level random effects on prescribing and on diagnosis were estimated in a series of mixed-effects regression models, including age, sex, weekday, month, and clinician characteristics as fixed effects. GPs were grouped into quintiles by antibiotic prescribing propensity, and described the proportion of patients they diagnosed with pharyngitis/tonsillitis or sore throat in each quintile.

RESULTS

The analysis dataset included 393 590 throat-related consultations with 6881 staff. Diagnosis of pharyngitis/tonsillitis was strongly associated with antibiotic prescribing (adjusted odds ratio = 13.41, 95% confidence interval = 12.8 to 14.04). GP random effect accounted for 18% of variation in prescribing and for 26% of variation in diagnosis. GPs in the lowest quintile of antibiotic prescribing propensity diagnosed pharyngitis/tonsillitis on 31% of occasions, compared with 55% in the highest quintile.

CONCLUSION

There is substantial variation among GPs in diagnosis and treatment of throat-related problems. Preference for a medicalising diagnosis is associated with a preference for antibiotics, suggesting a common propensity to both diagnose and treat.

Evidence of the Efficacy of Flurbiprofen 8.75 mg Lozenges for Patients Receiving Antibiotics for Laboratory-Confirmed Streptococcal Pharyngitis

OBJECTIVES

To determine the efficacy of flurbiprofen 8.75 mg lozenges for patients with laboratory-confirmed streptococcal pharyngitis both before and concomitant with antibiotics.

METHODS

This post hoc analysis comprised adult participants from 2 earlier randomized, double-blind, placebo-controlled studies evaluating the analgesic efficacy of flurbiprofen 8.75 mg lozenges in acute pharyngitis. Throat swabs were obtained to diagnose streptococcal infection. Prior to and 2 hours after each dose of study medication (flurbiprofen or placebo lozenges), patients rated 3 symptoms of acute pharyngitis (sore throat pain, difficulty swallowing, and swollen throat) using visual analogue scales. Appropriate antibiotic treatment was initiated when culture results were reported. Mean changes in each pharyngeal symptom were compared over the immediate 24 hours before and during the initial 24 hours of antibiotic treatment.

RESULTS

Twenty-four patients provided both preantibiotic and concomitant antibiotic efficacy outcomes. Relief of throat pain was 93% greater in the flurbiprofen group than in the placebo group before antibiotic coadministration and 84% greater than placebo during antibiotic administration (both P < .05). Relief of difficulty swallowing was 71% greater in the flurbiprofen group than in the placebo before antibiotic administration (P = .16) and 107% greater during concomitant antibiotic administration (P = .04). Relief of the sensation of throat swelling was 295% greater with flurbiprofen than placebo before antibiotic administration (P = .008) and 70% greater during concomitant antibiotic administration (P = .06). For placebo-treated patients, relief from throat pain and difficulty swallowing were similar before and during antibiotic treatment (P > .05), indicating no benefit with antibiotic administration for these symptoms. No treatment-related discontinuations or serious adverse events were reported.

CONCLUSIONS

Irrespective of antibiotic use, flurbiprofen 8.75 mg lozenges provide well-tolerated, effective relief of pharyngeal symptoms in patients with streptococcal infection. In the 24 hours after administration, antibiotics provide no relief of throat pain or difficulty swallowing beyond the topical demulcent effects of placebo lozenges.

Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial

BACKGROUND

Overprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model.

METHODS

Following qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout.

DISCUSSION

This study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303 .

Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations

Background

There is an ongoing debate on the indications for tonsil surgery in both children and adults with recurrent acute tonsillitis. The aim is to provide practical recommendations for diagnostics and treatment for recurrent acute tonsillitis including evidence-based decision making for tonsillectomy.

Methods

A systematic literature search in PubMed, Embase, Web of Science, and ScienceDirect from 2014 until April 2023 resulted in 68 articles. These were the basis for the review and a comprehensive series of consensus statements on the most important diagnostics and indications for both non-surgical and surgical therapy. A consensus paper was circulated among the authors and members of the International Head and Neck Scientific Group until a final agreement was reached for all recommendations.

Results

The differentiation between sore throat and tonsillitis patient episodes is mostly not feasible and hence is not relevant for diagnostic decision making. Diagnostics of a tonsillitis/sore throat episode should always include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS). In ambiguous cases, a point-of-care test GAS swab test is helpful. Consecutive counting of the tonsillitis/sore throat episodes is important. In addition, a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) should be used for each episode. Conservative treatment includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs. In case of high probability of bacterial tonsillitis, and only in such cases, especially in patients at risk, standard antibiotic treatment is initiated directly or by delayed prescription. Tonsillectomy is indicated and is highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years. An essential part of surgery is standardized pain management because severe postoperative pain can be expected in most patients.

Conclusion

It is necessary to follow a stringent treatment algorithm for an optimal and evidence-based treatment for patients with recurrent acute tonsillitis. This will help decrease worldwide treatment variability, antibiotic overuse, and avoid ineffective tonsillectomy.

The incidence and factors of inappropriate rapid antigen test usage for group A streptococcus

INTRODUCTION

Although rapid antigen tests (RADTs) for group A streptococcus (GAS) can help diagnose group A streptococcal pharyngitis, little is known about the inappropriate use of these RADTs.

METHODS

This retrospective observational study compared the appropriate vs. inappropriate use of RADTs in patients who had a RADT between January 2019 and August 2022. RADTs for patients with a low Centor score of 0-1 point were deemed inappropriate.

RESULTS

Of the 1015 patients, 380 (37.4%) had inappropriate RADTs. Patients with asthma were associated with an increased risk of inappropriate testing. In contrast, during the coronavirus 2019 pandemic, outpatients and residents were associated with a reduced risk of inappropriate testing. Consequent to the inappropriate use of RADTs, 162 (16.0%) patients received potentially inappropriate antibiotics.

CONCLUSIONS

Our results suggest that diagnostic stewardship for pharyngitis, including education for healthcare workers, is needed to reduce inappropriate test ordering and prevent unnecessary care.

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

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.

Influence of a guideline or an additional rapid strep test on antibiotic prescriptions for sore throat: the cluster randomized controlled trial of HALS (Hals und Antibiotika Leitlinien Strategien)

BACKGROUND

Pharyngitis due to Group A beta-hemolytic streptococci (GAS) is seen as the main indication for antibiotics for sore throat. In primary care settings prescription rates are much higher than the prevalence of GAS. Recommendations in international guidelines differ considerably. A German guideline suggested to consider antibiotics for patients with Centor or McIsaac scores ≥ 3, first choice being penicillin V for 7 days, and recommended analgesics for all. We investigated, if the implementation of this guideline lowers the antibiotic prescription rate, and if a rapid antigen detection strep-test (RADT) in patients with scores ≥ 3 lowers the rate further.

METHODS

HALS was an open pragmatic parallel group three-arm cluster-randomized controlled trial. Primary care practices in Northern Germany were randomized into three groups: Guideline (GL-group), modified guideline with a RADT for scores ≥ 3 (GL-RADT-group) or usual care (UC-group). All practices were visited and instructed by the study team (outreach visits) and supplied with material according to their group. The practices were asked to recruit 11 consecutive patients ≥ 2 years with an acute sore throat and being at least moderately impaired. A study throat swab for GAS was taken in every patient. The antibiotic prescription rate at the first consultation was the primary outcome.

RESULTS

From October 2010 to March 2012, 68 general practitioners in 61 practices recruited 520 patients, 516 could be analyzed for the primary endpoint. Antibiotic prescription rates did not differ between groups (p = 0.162) and were about three times higher than the GAS rate: GL-group 97/187 patients (52%; GAS = 16%), GL-RADT-group 74/172 (43%; GAS = 16%) and UC-group 68/157 (43%; GAS = 14%). In the GL-RADT-group 55% of patients had scores ≥ 3 compared to 35% in GL-group (p < 0.001). After adjustment, in the GL-RADT-group the OR was 0.23 for getting an antibiotic compared to the GL-group (p = 0.010), even though 35 of 90 patients with a negative Strep-test got an antibiotic in the GL-RADT-group. The prescription rates per practice covered the full range from 0 to 100% in all groups.

CONCLUSION

The scores proposed in the implemented guideline seem inappropriate to lower antibiotic prescriptions for sore throat, but better adherence of practitioners to negative RADTs should lead to fewer prescriptions.

TRIAL REGISTRATION

DRKS00013018, retrospectively registered 28.11.2017.

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

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.

Performance of a Molecular Test for Group A Streptococcus Pharyngitis

We performed a prospective study to determine if the pretest probability of a positive loop-mediated isothermal amplification test is greater when there are more signs and symptoms of GAS pharyngitis. Patients were enrolled if a clinician obtained a GAS RADT. The McIsaac score was calculated. The prevalence of positive LAMP and RADT results increased as the McIsaac score increased. The calculated sensitivity of LAMP was superior to RADT.

Standardizing Strep Throat Documentation in a Pediatric Outpatient Setting During COVID-19: A Quality Improvement Pilot Project

Clinicians' nonadherence to the 2012 Infectious Diseases Society of America's group A streptococcal (GAS) pharyngitis guidelines leads to unnecessary in-person clinic visits, unnecessary use of bacterial testing, and inappropriate antibiotic prescriptions. Quality improvement methodology was used during nurse telephone triage at an outpatient pediatric clinic to standardize nurse documentation to align with the GAS guidelines. This pilot project's standardization resulted in improved communication among clinicians and decreased unnecessary resource and antibiotic use despite encountering barriers related to COVID-19.

Diagnosis of group A streptococcal pharyngitis in the paediatric emergency department using a fluorescence-based RADT: predicted impact on antibiotic prescription

Introduction. Using rapid antigen diagnostic tests (RADTs) in clinical practice has shown excellent specificity but often has diminished sensitivity.Gap Statement. Local data for evaluating the diagnostic performance of a new fluorescence-based RADT and its influence on the antibiotic prescription rate are not available.Aim. To evaluate the accuracy of fluorescent immunoassay (FIA)-RADTs for diagnosing group A streptococcal (GAS) pharyngitis among children and its estimated effect as a point of care test (POCT) on the antibiotic prescription rate at the paediatric emergency department.Methodology. A prospective study was conducted, comprising children 3 to 14 years old presenting with pharyngitis. Throat swab culture and FIA-RADTs were performed on all samples. Conventional PCR was performed on the discordant samples.Results. A total of 246 children were included in this study. The sensitivity, specificity, and positive and negative predictive values of the FIA-RADT, based on culture results and PCR detection combined, were 95.6, 96.8, 94.6 and 97.4 %, respectively. Antibiotics have been prescribed to 162 (65.9 %) children; however, if FIA-RADTs had been added in the clinical practice as a POCT, only 92 (37.4 %) children would have received antibiotics in total. Additionally, implementation of FIA-RADTs would significantly reduce the antibiotic prescription rate from 48.8 and 60.6 % to 9.5 and 31.9 % among patients with clinical scores of 2 and 3, respectively.Conclusion. The new FIA-RADT is simple, prompt and reliable. It is helpful in clinical settings and may be used to reduce antibiotic overprescription, especially for children who have a low risk for GAS pharyngitis, according to the clinical score.

The Effect of Amoxicillin with Clavulanate on the Microbiota of Tonsillar Tissue in Disease: a Randomized Control Trial

Despite antibiotics being the primary medical treatment for recurrent tonsillitis, the impact of antibiotics on the tonsillar microbiome is not well understood. This study aimed to determine the effect of amoxicillin with clavulanate on the composition and quantity of bacteria in the tonsils of children with recurrent tonsillitis. A multicenter randomized clinical trial in Auckland, New Zealand was undertaken between August 1, 2017, and June 30, 2018. Sixty children undergoing tonsillectomy for the indication of recurrent tonsillitis were recruited for this study. Following random allocation, 30 participants were prescribed amoxicillin with clavulanate for the week before surgery. The remaining 30 received no antibiotics. Immediately following surgery, the crypts of the right and left tonsils were swabbed. Bacterial 16S rRNA gene-targeted amplicon sequencing and histological techniques were utilized. In the control group, there were significantly higher relative abundances of Haemophilus, Streptococcus, Neisseria, and Porphyromonas. Members from the genera Fusobacterium and Treponema were found to be significantly more abundant in the antibiotic group. There were no significant differences in the absolute quantities of bacteria between the groups. Microscopic examination found fewer bacterial microcolonies present in the tonsillar crypts of participants in the antibiotic group. Streptococcus pyogenes was not present in these bacterial microcolonies. These results suggest that a single course of antibiotics has a significant impact on the tonsil microbiota composition. The duration of this effect and the effect that the altered microbiome has on the course of the condition need to be determined. IMPORTANCE Several studies have identified the presence of multiple pathogenic bacteria in hyperplastic adenoids and palatine tonsils. However, there are currently no studies that utilize this technology to investigate the effect of oral antibiotics in children with recurrent tonsillitis on the tonsillar microbiome. This is the first study to investigate the effect of antibiotics on the microbiome of tonsillar tissue in children with recurrent tonsillitis using molecular techniques. This study has shown that participants who received amoxicillin with clavulanate immediately before tonsillectomy had a significantly reduced number of bacterial taxa commonly associated with recurrent tonsillitis, as well as the number of bacterial microcolonies observed in the tonsillar crypts. This novel finding suggests that either the effect of antibiotics is not sustained or that they are not an effective treatment for recurrent tonsillitis.

Use of Host Response to Refine the Diagnosis of Group A Streptococcal Pharyngitis

BACKGROUND

Current diagnostic tests for pharyngitis do not distinguish between symptomatic group A Streptococcus (GAS) infection and asymptomatic colonization, resulting in over-diagnosis and unnecessary use of antibiotics. We assessed whether measures of host response could make this distinction.

METHODS

We enrolled 18 children with pharyngitis having Centor scores of 4 or 5 and 21 controls without pharyngitis or other acute infections. Both groups had throat cultures, molecular tests for GAS and respiratory viruses and IgM serology for Epstein-Barr virus. Host response was evaluated with white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), and sequencing of RNA from peripheral blood leukocytes.

RESULTS

Of 18 cases, 11 had GAS pharyngitis, 3 had adenovirus pharyngitis and 4 had other pharyngitis. Among asymptomatic controls, 5 were positive for GAS. WBC, CRP, and PCT were higher in subjects with pharyngitis compared to asymptomatic controls including those with GAS. Transcriptional profiles from children with symptomatic GAS were clearly distinct from those of children in all other groups. The levels of two genes, CD177 and TLR5 each individually accurately distinguished between symptomatic and asymptomatic GAS. Optimal diagnostic sensitivity and specificity were achieved by the combination of CRP and PCT, and by each of the two gene markers.

CONCLUSION

In this exploratory study, we showed that traditional measures of inflammation and markers of host gene expression distinguish between symptomatic and asymptomatic GAS. These results point to future rapid molecular approaches for improving the diagnosis of GAS pharyngitis, that may help reduce unnecessary antibiotic use.

Foodborne streptococcal tonsillopharyngitis outbreak in a hospital

OBJECTIVE

Group A beta-haemolytic streptococci (GAS), which are responsible for most cases of acute bacterial tonsillopharyngitis, are transmitted from person to person and may rarely cause foodborne outbreaks. This study aims to report the epidemic caused by GAS in our hospital and to draw attention to the explosive outbreaks of the bacteria.

METHODS

Acute tonsillopharyngitis was seen in 201 of 450 hospital employees who ate in the hospital cafeteria on 4-5 June 2015.

RESULTS

GAS was detected in 106 (68%) of 157 cases and in 40 (63.5%) of 62 throat culture samples. The attack rate was 44.7%. The most suspected source of the outbreak was a food handler who had been showing signs of streptococcal tonsillopharyngitis for six days, and perhaps the food prepared by these staff.

CONCLUSION

It should not be forgotten that GAS can cause explosive outbreaks by infecting food through hand lesions or mouth secretions of food service personnel.

Throat infections and use of streptococcal antigen test and antibiotic treatment in general practice; a web-based survey

OBJECTIVE

The aim of this study was to investigate the use of streptococcal antigen tests and antibiotic prescription in general practice in Norway in relation to the national guidelines for sore throat.

DESIGN

This study was based on a web-based survey.

SETTING

Norwegian general practice.

SUBJECTS

4700 members of the Norwegian College of General Practice received the survey by E-mail.

MAIN OUTCOME MEASURES

General practitioner (GP) adherence to national guidelines.

RESULTS

In total, 807 GPs responded and were included in the study. According to the guidelines, 20% and 30% of the GPs would perform unnecessary streptococcal antigen testing when presented with mild and severe infections respectively, while 52% would not perform the test at moderate infection. Phenoxymethylpenicillin was recommended by 95% of the GPs.

CONCLUSION

In this survey of self-selected GPs, we identified some non-adherence to National guidelines for streptococcal antigen testing and antibiotic prescribing. However, when antibiotic treatment was offered, the correct antibiotics were prescribed.Key pointsNorwegian guidelines for diagnosis and treatment of throat infections include the use of Centor criteria as a clinical tool to limit the unnecessary use of antibiotics. In this web-based survey, we investigated the use of streptococcal antigen tests and antibiotic prescription in general practice in relation to the national guidelines.•Streptococcal antigen tests were not always performed according to Norwegian guidelines, causing inappropriate antibiotic prescribing.•National guidelines were followed in the choice of antibiotics for sore throat.

Clinical course of pharyngotonsillitis with group A streptococcus treated with different penicillin V strategies, divided in groups of Centor Score 3 and 4: a prospective study in primary care

Background

Sore throat is a common reason for prescribing antibiotics in primary care, and 10 days of treatment is recommended for patients with pharyngotonsillitis with group A streptococcus (GAS). Our group recently showed that penicillin V (PcV) four times daily for 5 days was non-inferior in clinical outcome to PcV three times daily for 10 days. This study compares duration, intensity of symptoms, and side effects in patients with a Centor Score (CS) of 3 or 4 respectively, after treatment with PcV for 5 or 10 days and evaluates whether all patients with pharyngotonsillitis with a CS of 3 or 4 should be treated for 5 days or if severity of symptoms or CS suggest a longer treatment period.

Method

Data on symptoms and recovery from patient diaries from 433 patients included in a RCT comparing PcV 800 mg × 4 for 5 days or PcV 1 g × 3 for 10 days was used. Patients six years and older with CS-3 or CS-4 and positive rapid antigen detection test for GAS-infection were grouped based on CS and randomized treatment. Comparisons for categorical variables were made with Pearson’s chi-squared test or Fisher’s exact test. Continuous variables were compared with the Mann–Whitney U test.

Results

Patients with CS-3 as well as patients with CS-4 who received PcV 800 mg × 4 for 5 days self-reported that they recovered earlier compared to patients with CS-3 or CS-4 who received treatment with PcV 1 g × 3 for 10 days. In addition, the throat pain as single symptom was relieved 1 day earlier in patients with CS-4 and 5 days of treatment compared to patients with CS-4 and 10 days of treatment. No differences in side effects between the groups were found.

Conclusion

Intense treatment with PcV four times a day for 5 days seems clinically beneficial and strengthens the suggestion that the 4-dose regimen with 800 mg PcV for 5 days may be the future treatment strategy for GAS positive pharyngotonsillitis irrespectively of CS-3 or CS-4.

Trail registration ClinicalTrials.gov ID: NCT02712307 (3 April 2016).

Knowledge, Attitude, and Practice of House Officers to the Diagnosis and Management of Bacterial Pharyngitis: A Multicenter Cross-Sectional Study

BACKGROUND

Pharyngitis is one of the most common clinical presentations in pediatric clinics. Streptococcal pharyngitis reaches a nadir in the early school years, and it is vital to diagnose it early to avoid the serious complications that can arise from improper treatment, such as acute rheumatic fever and rheumatic heart disease.

MATERIALS AND METHODS

This is a cross-sectional multicenter study of medical house officers conducted from January to February 2018.

RESULTS

This study surveyed 135 house officers at Khartoum's primary health centers and hospitals. Most of the respondents were males (76/135; 56%). Most of the house officers reported seeing patients with throat complaints 1-2 times per week (58/135; 43%). The most common complication was acute rheumatic fever (65/135; 48%). Out of all the criteria of a Group A beta-hemolytic streptococcus (GAS) pharyngitis diagnosis, absence of cough and tender lymph nodes were the least recognized by house officers, i.e. 11.9% (16/135) and 45.2% (61/135), respectively. Only (4/135) 3% knew the full criteria for diagnosing bacterial pharyngitis. Throat culture was the most commonly used lab test to diagnose bacterial pharyngitis (115/135; 85.2%). The majority of participants did not recognize an IM injection of benzathine penicillin G as the first-line management of bacterial pharyngitis (101/135; 74.8%). The participants had moderate knowledge (93/135; 68.9%). Those with poor knowledge also happened to have poor practice (p = 0.009). Those who see more cases per week were also more likely to have good knowledge (p = 0.000). House officers with a moderate attitude constituted about 48.9% (66/135) of the whole sample. The most often prescribed medication was amoxicillin-clavulanic acid for one week (53/135; 39.3%). The practice score was associated with a lower knowledge (p = 0.009). Only 20.7% (28/135) of the participants in our study were adherent to the use of benzathine penicillin G as the first-line management of bacterial pharyngitis.

CONCLUSION

House officers had poor-to-moderate knowledge regarding the diagnosis and management of bacterial pharyngitis, especially in regard to what antibiotic to use. However, their fear of antibiotic resistance was a good behavior.

Development and internal validation of risk scores to diagnose infectious mononucleosis among college students

BACKGROUND

Individual symptoms and signs of infectious mononucleosis (IM) are of limited value for diagnosis.

OBJECTIVE

To develop and validate risk scores based on signs and symptoms with and without haematologic parameters for the diagnosis of IM.

DESIGN AND SETTING

Data were extracted from electronic health records of a university health centre and were divided into derivation (9/1/2015-10/31/2017) and a prospective temporal internal validation (11/1/2017-1/31/2019) cohort.

METHOD

Independent predictors for the diagnosis of IM were identified in univariate analysis using the derivation cohort. Logistic regression models were used to develop 2 risk scores: 1 with only symptoms and signs (IM-NoLab) and 1 adding haematologic parameters (IM-Lab). Point scores were created based on the regression coefficients, and patients were grouped into risk groups. Primary outcomes were area under the receiver operating characteristic curve (AUROCC) and classification accuracy.

RESULTS

The IM-NoLab model had 4 predictors and identified a low-risk group (7.9% with IM) and a high-risk group (22.2%) in the validation cohort. The AUROCC was 0.75 in the derivation cohort and 0.69 in the validation cohort. The IM-Lab model had 3 predictors and identified a low-risk group (3.6%), a moderate-risk group (12.5%), and a high-risk group (87.6%). The AUROCC was 0.97 in the derivation cohort and 0.93 in the validation cohort.

CONCLUSION

We derived and internally validated the IM-NoLab and IM-Lab risk scores. The IM-Lab score in particular had very good discrimination and have the potential to reduce the need for diagnostic testing for IM.

Standardization of Epidemiological Surveillance of Group A Streptococcal Pharyngitis

Pharyngitis, more commonly known as sore throat, is caused by viral and/or bacterial infections. Group A Streptococcus (Strep A) is the most common bacterial cause of pharyngitis. Strep A pharyngitis is an acute, self-limiting disease but if undertreated can lead to suppurative complications, nonsuppurative poststreptococcal immune-mediated diseases, and toxigenic presentations. We present a standardized surveillance protocol, including case definitions for pharyngitis and Strep A pharyngitis, as well as case classifications that can be used to differentiate between suspected, probable, and confirmed cases. We discuss the current tests used to detect Strep A among persons with pharyngitis, including throat culture and point-of-care tests. The type of surveillance methodology depends on the resources available and the objectives of surveillance. Active surveillance and laboratory confirmation is the preferred method for case detection. Participant eligibility, the surveillance population and additional considerations for surveillance of pharyngitis are addressed, including baseline sampling, community engagement, frequency of screening and season. Finally, we discuss the core elements of case report forms for pharyngitis and provide guidance for the recording of severity and pain associated with the course of an episode.

Associations Between Findings of Fusobacterium necrophorum or β-Hemolytic Streptococci and Complications in Pharyngotonsillitis-A Registry-Based Study in Southern Sweden

BACKGROUND

Most pharyngotonsillitis guidelines focus on the identification of group A streptococci (GAS), guided by clinical scores determining whom to test with a rapid antigen detection test. Nevertheless, many patients testing negative with this test are evaluated for group C/G streptococci (GCS/GGS) and Fusobacterium necrophorum, yet their importance remains debated. Our primary aim was to evaluate associations between complications and findings of F. necrophorum, GAS, or GCS/GGS in pharyngotonsillitis.

METHODS

This was a retrospective, registry-based study of pharyngotonsillitis cases tested for F. necrophorum (polymerase chain reaction) and β-hemolytic streptococci (culture) in the Skåne Region, Sweden, in 2013-2020. Patients with prior complications or antibiotics (within 30 days) were excluded. Data were retrieved from registries and electronic charts. Logistic regression analyses were performed with a dichotomous composite outcome of complications as primary outcome, based on International Classification of Diseases, Tenth Revision, codes. Cases with negative results (polymerase chain reaction and culture) were set as reference category. Complications within 30 days were defined as peritonsillar or pharyngeal abscess, otitis, sinusitis, sepsis or septic complications, recurrence of pharyngotonsillitis (after 15-30 days) or hospitalization.

RESULTS

Of 3700 registered cases, 28% had F. necrophorum, 13% had GCS/GGS, 10% had GAS, and 54% had negative results. The 30-day complication rates were high (20%). F. necrophorum (odds ratio, 1.8; 95% confidence interval, 1.5-2.1) and GAS (1.9; 1.5-2.5) were positively associated with complications, whereas GCS/GGS were negatively associated (0.7; 0.4-0.98).

CONCLUSIONS

Our results indicate that F. necrophorum is a relevant pathogen in pharyngotonsillitis, whereas the relevance of testing for GCS/GGS is questioned. However, which patient to test and treat for F. necrophorum remains to be defined.

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

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.

Burnout in Pediatric Emergency Medicine Physicians: A Predictive Model

OBJECTIVES

This study aims to determine the prevalence of and identify predictors associated with burnout in pediatric emergency medicine (PEM) physicians and to construct a predictive model for burnout in this population to stratify risk.

METHODS

We conducted a cross-sectional electronic survey study among a random sample of board-certified or board-eligible PEM physicians throughout the United States and Canada. Our primary outcome was burnout assessed using the Maslach Burnout Inventory on 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. We defined burnout as scoring in the high-degree range on any 1 of the 3 subscales. The Maslach Burnout Inventory was followed by questions on personal demographics and work environment. We compared PEM physicians with and without burnout using multivariable logistic regression.

RESULTS

We studied a total of 416 PEM board-certified/eligible physicians (61.3% women; mean age, 45.3 ± 8.8 years). Surveys were initiated by 445 of 749 survey recipients (59.4% response rate). Burnout prevalence measured 49.5% (206/416) in the study cohort, with 34.9% (145/416) of participants scoring in the high-degree range for emotional exhaustion, 33.9% (141/416) for depersonalization, and 20% (83/416) for personal accomplishment. A multivariable model identified 6 independent predictors associated with burnout: 1) lack of appreciation from patients, 2) lack of appreciation from supervisors, 3) perception of an unfair clinical work schedule, 4) dissatisfaction with promotion opportunities, 5) feeling that the electronic medical record detracts from patient care, and 6) working in a nonacademic setting (area under the receiver operating characteristic curve, 0.77). A predictive model demonstrated that physicians with 5 or 6 predictors had an 81% probability of having burnout, whereas those with zero predictors had a 28% probability of burnout.

CONCLUSIONS

Burnout is prevalent in PEM physicians. We identified 6 independent predictors for burnout and constructed a scoring system that stratifies probability of burnout. This predictive model may be used to guide organizational strategies that mitigate burnout and improve physician well-being.

[Modern approaches to the surgical treatment of chronic tonsillitis]

At the moment, all over the world there are a large number of various methods of surgical treatment of chronic tonsillitis. In particular: classical tonsillectomy, cryosurgical method for removing the palatine tonsils, shaver tonsillectomy, monopolar and bipolar tonsillectomy, tonsillectomy with an ultrasonic scalpel, bipolar dissection using cutting instruments, laser tonsillectomy, coldablation. This article analyzes the existing methods, describes the fundamental technique for their implementation, as well as their advantages and disadvantages. Given the abundance of various surgical approaches to the treatment of chronic tonsillitis, there is a need for studies aimed at comparative study of their clinical and microbiological efficacy, including the postoperative period.