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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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Milani GP, Rosa C, Tuzger N, Alberti I, Ghizzi C, Zampogna S, Amigoni A, Agostoni C, Peroni D, Marchisio P, Chiappini E. Nationwide survey on the management of pediatric pharyngitis in Italian emergency units. Ital J Pediatr 2023; 49:114. [PMID: 37670391 PMCID: PMC10481466 DOI: 10.1186/s13052-023-01514-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/19/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Acute pharyngitis is a frequent reason for primary care or emergency unit visits in children. Most available data on pharyngitis management come from primary care studies that demonstrate an underuse of microbiological tests, a tendency to over-prescribe antibiotics and a risk of antimicrobial resistance increase. However, a comprehensive understanding of acute pharyngitis management in emergency units is lacking. This study aimed to investigate the frequency of rapid antigen test use to diagnose acute pharyngitis, as well as other diagnostic approaches, the therapeutic attitude, and follow-up of children with this condition in the emergency units. METHODS A multicentric national study was conducted in Italian emergency departments between April and June 2022. RESULTS A total of 107 out of 131 invited units (response rate 82%), participated in the survey. The results showed that half of the units use a scoring system to diagnose pharyngitis, with the McIsaac score being the most commonly used. Most emergency units (56%) were not provided with a rapid antigen diagnostic test by their hospital, but the test was more frequently available in units visiting more than 10,000 children yearly (57% vs 33%, respectively, p = 0.02). Almost half (47%) of the units prescribe antibiotics in children with pharyngitis despite the lack of microbiologically confirmed cases of Group A β-hemolytic streptococcus. Finally, about 25% of units prescribe amoxicillin-clavulanic acid to treat Group A β-hemolytic streptococcus pharyngitis. CONCLUSIONS The study sheds light on the approach to pharyngitis in emergency units, providing valuable information to improve the appropriate management of acute pharyngitis in this setting. The routinary provision of rapid antigen tests in the hospitals could enhance the diagnostic and therapeutic approach to pharyngitis.
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Affiliation(s)
- Gregorio P Milani
- Pediatric Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Della Commenda 9, 20122, Milan, Italy.
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.
| | - Claudio Rosa
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Naz Tuzger
- Pediatric Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Della Commenda 9, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Ilaria Alberti
- Pediatric Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Della Commenda 9, 20122, Milan, Italy
| | | | - Stefania Zampogna
- SOC Pediatria, Azienda Sanitaria Provinciale Di Crotone, Crotone, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Carlo Agostoni
- Pediatric Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Della Commenda 9, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Diego Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Paola Marchisio
- Pediatric Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Della Commenda 9, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Elena Chiappini
- Pediatric Infectious Disease Unit, Department of Health Sciences, Meyer Children's University Hospital, University of Florence, Florence, Italy
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Diagnostic Stewardship—The Impact of Rapid Diagnostic Testing for Paediatric Respiratory Presentations in the Emergency Setting: A Systematic Review. CHILDREN 2022; 9:children9081226. [PMID: 36010116 PMCID: PMC9406643 DOI: 10.3390/children9081226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/06/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022]
Abstract
Antimicrobial resistance is a growing public health crisis, propelled by inappropriate antibiotic prescription, in particular the over-prescription of antibiotics, prolonged duration of antibiotic therapy and the overuse of broad-spectrum antibiotics. The paediatric population, in particular, those presenting to emergency settings with respiratory symptoms, have been associated with a high rate of antibiotic prescription rates. Further research has now shown that many of these antibiotic prescriptions may have been avoided, with more targeted diagnostic methods to identify underlying aetiologies. The purpose of this systematic review was to assess the impact of rapid diagnostic testing, for paediatric respiratory presentations in the emergency setting, on antibiotic prescription rates. To review the relevant history, a comprehensive search of Medline, EMBASE and Cochrane Database of Systematic Reviews was performed. Eighteen studies were included in the review, and these studies assessed a variety of rapid diagnostic testing tools and outcome measures. Overall, rapid diagnostic testing was found to be an effective method of diagnostic antibiotic stewardship with great promise in improving antibiotic prescribing behaviours. Further studies are required to evaluate the use of rapid diagnostic testing with other methods of antibiotics stewardship, including clinical decisions aids and to increase the specificity of interventions following diagnosis to further reduce rates of antibiotic prescription.
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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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Acar T, Ertekin B, Girisgin AS, Öztürk E, Bilgi S. Efficiency of Rapid Antigen Test in Diagnosis of Acute Streptococcal Tonsillopharyngitis. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2019. [DOI: 10.33808/clinexphealthsci.600033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Acar T, Ertekin B, Girisgin AS, Öztürk E, Bilgi S. Efficiency of Rapid Antigen Test in Diagnosis of Acute Streptococcal Tonsillopharyngitis. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2019. [DOI: 10.33808/marusbed.600033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cag Y, Özdemir AA, Yükselmiş U, Akdeniz E, Özçetin M. Association Between Rapid Antigen Testing and Antibiotic Use and Accuracy of Peripheral Blood Parameters in Detecting Group A Streptococcus in Children With Tonsillopharyngitis. Front Pediatr 2019; 7:322. [PMID: 31428594 PMCID: PMC6688128 DOI: 10.3389/fped.2019.00322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/18/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives: To investigate the effect of rapid antigen testing (RAT) on the practice of antibiotic prescription as well as the accuracy of peripheral blood neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) values in detecting group A beta-hemolytic Streptococcus (GABHS) in children with tonsillopharyngitis. Methods: In a multicenter study performed in Turkey, we retrospectively analyzed data from 668 consecutive pediatric patients under 17 years of age, who presented with signs and symptoms of tonsillopharyngitis and underwent RAT. The rates of positive and negative RAT results were determined and patients' antibiotic prescriptions were examined in relation to RAT results. In addition, the accuracy of peripheral blood NLR and CRP values was examined for 212 patients whose laboratory data were available, with RAT as the reference standard. Results: Positive RAT results were observed in 190 of 668 (28.4%) patients. Antibiotics were prescribed to all 190 patients with positive RAT results and to 8 of 478 patients with negative RAT results. Overall, the rate of antibiotic prescription was 29.6%. Patients with positive and negative RAT results did not differ significantly with regard to NLR and CRP values. In ROC analysis, the area under the ROC curve (AUC) of NLR and CRP were 0.54 (95% confidence interval [CI] 0.45-0.64), and 0.55 (95% CI 0.45-0.65), respectively. Conclusion: RAT results proved highly associated with antibiotic prescribing, suggesting that RATs could be of great value in preventing unnecessary antibiotic use. Our findings also suggest that NLR and CRP are poorly accurate to identify GABHS in children with tonsillopharyngitis.
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Affiliation(s)
- Yakup Cag
- Department of Pediatrics, Kartal Dr. Lutfi Kırdar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | | | - Ufuk Yükselmiş
- Department of Pediatrics, Kartal Dr. Lutfi Kırdar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ezgi Akdeniz
- Department of Pharmacy, Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mustafa Özçetin
- Department of Pediatrics, Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Muthanna A, Salim HS, Hamat RA, Shamsuddin NH, Zakariah SZ. Clinical Screening Tools to Diagnose Group A Streptococcal Pharyngotonsillitis in Primary Care Clinics to Improve Prescribing Habits. Malays J Med Sci 2018; 25:6-21. [PMID: 30914875 PMCID: PMC6422577 DOI: 10.21315/mjms2018.25.6.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 07/30/2018] [Indexed: 12/02/2022] Open
Abstract
This review highlights the clinical scoring tools used for the management of acute pharyngotonsillitis in primary care clinics. It will include the prevalence of group A pharyngotonsillitis among children and adults worldwide and the selective tests employed for diagnosing group A streptococcal pharyngotonsillitis. Pharyngotonsillitis is one of the common reasons for visits to primary care clinics worldwide, and physicians tend to prescribe antibiotics according to the clinical symptoms, which leads to overprescribing antibiotics. This in turn may lead to serious health impacts and severe reactions and may promote antibiotic resistance. These significantly add on to the health care costs. The available information from health organisations and previous studies has indicated the need to manage the diagnosis of pharyngotonsillitis to improve prescribing habits in primary care clinics.
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Affiliation(s)
- Abdulrahman Muthanna
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia
| | - Hani Syahida Salim
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia
| | - Rukman Awang Hamat
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia
| | - Nurainul Hana Shamsuddin
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia
| | - Siti Zulaikha Zakariah
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia
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Cohen JF, Bertille N, Cohen R, Chalumeau M. Rapid antigen detection test for group A streptococcus in children with pharyngitis. Cochrane Database Syst Rev 2016; 7:CD010502. [PMID: 27374000 PMCID: PMC6457926 DOI: 10.1002/14651858.cd010502.pub2] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Group A streptococcus (GAS) accounts for 20% to 40% of cases of pharyngitis in children; the remaining cases are caused by viruses. Compared with throat culture, rapid antigen detection tests (RADTs) offer diagnosis at the point of care (within five to 10 minutes). OBJECTIVES To determine the diagnostic accuracy of RADTs for diagnosing GAS in children with pharyngitis. To assess the relative diagnostic accuracy of the two major types of RADTs (enzyme immunoassays (EIA) and optical immunoassays (OIA)) by indirect and direct comparison. SEARCH METHODS We searched CENTRAL, MEDLINE, EMBASE, Web of Science, CDSR, DARE, MEDION and TRIP (January 1980 to July 2015). We also conducted related citations tracking via PubMed, handsearched reference lists of included studies and relevant review articles, and screened all articles citing included studies via Google Scholar. SELECTION CRITERIA We included studies that compared RADT for GAS pharyngitis with throat culture on a blood agar plate in a microbiology laboratory in children seen in ambulatory care. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, assessed full texts for inclusion, and carried out data extraction and quality assessment using the QUADAS-2 tool. We used bivariate meta-analysis to estimate summary sensitivity and specificity, and to investigate heterogeneity across studies. We compared the accuracy of EIA and OIA tests using indirect and direct evidence. MAIN RESULTS We included 98 unique studies in the review (116 test evaluations; 101,121 participants). The overall methodological quality of included studies was poor, mainly because many studies were at high risk of bias regarding patient selection and the reference standard used (in 73% and 43% of test evaluations, respectively). In studies in which all participants underwent both RADT and throat culture (105 test evaluations; 58,244 participants; median prevalence of participants with GAS was 29.5%), RADT had a summary sensitivity of 85.6%; 95% confidence interval (CI) 83.3 to 87.6 and a summary specificity of 95.4%; 95% CI 94.5 to 96.2. There was substantial heterogeneity in sensitivity across studies; specificity was more stable. There was no evidence of a trade-off between sensitivity and specificity. Heterogeneity in accuracy was not explained by study-level characteristics such as whether an enrichment broth was used before plating, mean age and clinical severity of participants, and GAS prevalence. The sensitivity of EIA and OIA tests was comparable (summary sensitivity 85.4% versus 86.2%). Sensitivity analyses showed that summary estimates of sensitivity and specificity were stable in low risk of bias studies. AUTHORS' CONCLUSIONS In a population of 1000 children with a GAS prevalence of 30%, 43 patients with GAS will be missed. Whether or not RADT can be used as a stand-alone test to rule out GAS will depend mainly on the epidemiological context. The sensitivity of EIA and OIA tests seems comparable. RADT specificity is sufficiently high to ensure against unnecessary use of antibiotics. Based on these results, we would expect that amongst 100 children with strep throat, 86 would be correctly detected with the rapid test while 14 would be missed and not receive antibiotic treatment.
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Affiliation(s)
- Jérémie F Cohen
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes UniversityObstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)ParisFrance
- Necker Hospital, AP‐HP and Paris Descartes UniversityDepartment of PediatricsParisFrance
| | - Nathalie Bertille
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes UniversityObstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)ParisFrance
| | - Robert Cohen
- Association Clinique et Thérapeutique Infantile du Val‐de‐Marne (ACTIV)27 Rue InkermannSaint‐Maur‐des‐FossésFrance
- Centre Hospitalier Intercommunal de Créteil (CHIC)Department of Microbiology40 avenue de VerdunCréteilFrance94010
| | - Martin Chalumeau
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes UniversityObstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)ParisFrance
- Necker Hospital, AP‐HP and Paris Descartes UniversityDepartment of PediatricsParisFrance
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Passos SD. [Diagnosing streptococcal pharyngotonsillitis in children and adolescents: the limitations of the clinical features]. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2014; 32:283-4. [PMID: 25510989 PMCID: PMC4311779 DOI: 10.1016/j.rpped.2014.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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de Moraes-Pinto MI. Streptococcal pharyngotonsillitis: need of microbiological tests in order to have a precise diagnosis. REVISTA PAULISTA DE PEDIATRIA 2013; 31:2-3. [PMID: 23703036 DOI: 10.1590/s0103-05822013000100001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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