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陈 思, 郭 孟, 邓 江, 姚 开. [Clinical diagnosis of group A streptococcal pharyngitis and progress in the application of scoring systems]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:893-898. [PMID: 39148397 PMCID: PMC11334548 DOI: 10.7499/j.issn.1008-8830.2403044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/24/2024] [Indexed: 08/17/2024]
Abstract
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.
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Affiliation(s)
| | | | - 江红 邓
- 国家儿童医学中心/首都医科大学附属北京儿童医院风湿科北京100045
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Tolley A, Bansal A, Murerwa R, Howard Dicks J. Cost-effectiveness of point-of-care diagnostics for AMR: a systematic review. J Antimicrob Chemother 2024; 79:1248-1269. [PMID: 38498622 PMCID: PMC11144491 DOI: 10.1093/jac/dkae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/19/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a major threat to global health. By 2050, it is forecast that AMR will cause 10 million deaths and cost 100 trillion USD annually. Point-of-care tests (POCTs) may represent a cost-effective approach to reduce AMR. OBJECTIVES We systematically reviewed which POCTs addressing AMR have undergone economic evaluation in primary and secondary healthcare globally, how these POCTs have been economically evaluated, and which are cost-effective in reducing antimicrobial prescribing or the burden of AMR. Clinical cost-effectiveness was additionally addressed. METHODS This systematic review, accordant with PRISMA guidelines, was pre-registered on PROSPERO (CRD42022315192). MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar were searched from 2000 to 2023 for relevant publications. Quality assessment was performed using the Consensus of Health Economic Criteria. RESULTS The search strategy identified 1421 studies, of which 20 met the inclusion criteria. The most common POCTs assessed were for respiratory infections (n = 10), STIs (n = 3), and febrile patients in low- and middle-income countries (n = 3). All studies assessed costs from a healthcare provider perspective; five additionally considered the societal cost of AMR.Eighteen studies identified POCT strategies that reduced antimicrobial prescribing. Of these, 10 identified POCTs that would be considered cost-effective at a willingness-to-pay (WTP) threshold of £33.80 per antibiotic prescription avoided. Most POCT strategies improved clinical outcomes (n = 14); the remainder were clinically neutral. CONCLUSIONS There is evidence that some POCTs are cost-effective in reducing antimicrobial prescribing, with potential concomitant clinical benefits. Such interventions-especially CRP POCTs in both high- and low-income settings-merit further, large-scale clinical evaluation.
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Affiliation(s)
- Abraham Tolley
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Akhil Bansal
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Internal Medicine, St Vincent’s Hospital, Sydney, Australia
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Kanagasabai A, Evans C, Jones HE, Hay AD, Dawson S, Savović J, Elwenspoek MMC. Systematic review and meta-analysis of the accuracy of McIsaac and Centor score in patients presenting to secondary care with pharyngitis. Clin Microbiol Infect 2024; 30:445-452. [PMID: 38182052 DOI: 10.1016/j.cmi.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 12/11/2023] [Accepted: 12/24/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Centor and McIsaac scores are clinical prediction rules for diagnosing group A streptococcus (GAS) infection in patients with pharyngitis. Their recommended thresholds vary between guidelines. OBJECTIVES To estimate the sensitivity and specificity of the McIsaac and Centor scores to diagnose GAS pharyngitis and evaluate their impact on antibiotic prescribing at each threshold in patients presenting to secondary care. DATA SOURCES MEDLINE, Embase, and Web of Science were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA Studies of patients presenting with acute pharyngitis to emergency or outpatient clinics that estimated the accuracy of McIsaac or Centor scores against throat cultures and/or rapid antigen detection tests (RADT) as reference standards. TESTS Centor or McIsaac score. REFERENCE STANDARD Throat cultures and/or RADT. ASSESSMENT OF RISK OF BIAS Quality Assessment of Diagnostic Accuracy Studies. METHODS OF DATA SYNTHESIS The sensitivities and specificities of the McIsaac and Centor scores were pooled at each threshold using bivariate random effects meta-analysis. RESULTS Fourteen studies were included (eight McIsaac and six Centor scores). Eight studies had unclear and six had a high risk of bias. The McIsaac score had higher estimated sensitivity and lower specificity relative to Centor scores at equivalent thresholds but with wide and overlapping confidence regions. Using either score as a triage to RADT to decide antibiotic treatment would reduce antibiotic prescription to patients with non-GAS pharyngitis relative to RADT test for everyone, but also reduce antibiotic prescription to patients with GAS. DISCUSSION Centor and McIsaac scores are equally ineffective at triaging patients who need antibiotics presenting with pharyngitis at hospitals. At high thresholds, too many true positive cases are missed, whereas at low thresholds, too many false positives are treated, leading to the over prescription of antibiotics. The former may be compensated by adequate safety netting by clinicians, ensuring that patients can seek help if symptoms worsen.
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Affiliation(s)
| | - Callum Evans
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Martha M C Elwenspoek
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Bakhit M, Gamage SK, Atkins T, Glasziou P, Hoffmann T, Jones M, Sanders S. Diagnostic performance of clinical prediction rules to detect group A beta-haemolytic streptococci in people with acute pharyngitis: a systematic review. Public Health 2024; 227:219-227. [PMID: 38241903 DOI: 10.1016/j.puhe.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 01/21/2024]
Abstract
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.
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Affiliation(s)
- Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | | | - Tiffany Atkins
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Sharon Sanders
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
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Lown M, Smith KA, Muller I, Woods C, Maund E, Rogers K, Becque T, Hayward G, Moore M, Little P, Glogowska M, Hay A, Stuart B, Mantzourani E, Wilcox CR, Thompson N, Francis NA. Internet Tool to Support Self-Assessment and Self-Swabbing of Sore Throat: Development and Feasibility Study. J Med Internet Res 2023; 25:e39791. [PMID: 38064265 PMCID: PMC10746968 DOI: 10.2196/39791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/14/2023] [Accepted: 11/14/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Sore throat is a common problem and a common reason for the overuse of antibiotics. A web-based tool that helps people assess their sore throat, through the use of clinical prediction rules, taking throat swabs or saliva samples, and taking throat photographs, has the potential to improve self-management and help identify those who are the most and least likely to benefit from antibiotics. OBJECTIVE We aimed to develop a web-based tool to help patients and parents or carers self-assess sore throat symptoms and take throat photographs, swabs, and saliva samples for diagnostic testing. We then explored the acceptability and feasibility of using the tool in adults and children with sore throats. METHODS We used the Person-Based Approach to develop a web-based tool and then recruited adults and children with sore throats who participated in this study by attending general practices or through social media advertising. Participants self-assessed the presence of FeverPAIN and Centor score criteria and attempted to photograph their throat and take throat swabs and saliva tests. Study processes were observed via video call, and participants were interviewed about their views on using the web-based tool. Self-assessed throat inflammation and pus were compared to clinician evaluation of patients' throat photographs. RESULTS A total of 45 participants (33 adults and 12 children) were recruited. Of these, 35 (78%) and 32 (71%) participants completed all scoring elements for FeverPAIN and Centor scores, respectively, and most (30/45, 67%) of them reported finding self-assessment relatively easy. No valid response was provided for swollen lymph nodes, throat inflammation, and pus on the throat by 11 (24%), 9 (20%), and 13 (29%) participants respectively. A total of 18 (40%) participants provided a throat photograph of adequate quality for clinical assessment. Patient assessment of inflammation had a sensitivity of 100% (3/3) and specificity of 47% (7/15) compared with the clinician-assessed photographs. For pus on the throat, the sensitivity was 100% (3/3) and the specificity was 71% (10/14). A total of 89% (40/45), 93% (42/45), 89% (40/45), and 80% (30/45) of participants provided analyzable bacterial swabs, viral swabs, saliva sponges, and saliva drool samples, respectively. Participants were generally happy and confident in providing samples, with saliva samples rated as slightly more acceptable than swab samples. CONCLUSIONS Most adult and parent participants were able to use a web-based intervention to assess the clinical features of throat infections and generate scores using clinical prediction rules. However, some had difficulties assessing clinical signs, such as lymph nodes, throat pus, and inflammation, and scores were assessed as sensitive but not specific. Many participants had problems taking photographs of adequate quality, but most were able to take throat swabs and saliva samples.
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Affiliation(s)
- Mark Lown
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Kirsten A Smith
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Ingrid Muller
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Catherine Woods
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Emma Maund
- School of Healthcare Enterprise and Innovation, University of Southampton, Southampton, United Kingdom
| | - Kirsty Rogers
- Local Clinical Research Network Wessex, Southampton, United Kingdom
| | - Taeko Becque
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Michael Moore
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Paul Little
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Margaret Glogowska
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Alastair Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Beth Stuart
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, United Kingdom
| | - Efi Mantzourani
- Cardiff School of Pharmacy, Cardiff University, Cardiff, United Kingdom
| | | | - Natalie Thompson
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Nick A Francis
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
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Hashmi FK, Khadka S, Yadav GK, Khan MM, Khan SU, Saeed H, Saleem M, Giri S, Rasool MF, Mansoor HUH, Riboua Z. Non-prescription antibiotics dispensing by community pharmacies: implications for antimicrobial resistance. Ann Med Surg (Lond) 2023; 85:5899-5907. [PMID: 38098592 PMCID: PMC10718340 DOI: 10.1097/ms9.0000000000001388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/28/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction The non-prescription antibiotics dispensing (NPAD) from pharmacies is on the rise in low- and middle-income countries, which contributes to the emergence of antimicrobial resistance (AMR). This study was conducted with the objective to determine the community pharmacy personnel's perspectives on NPAD and its implications for AMR. Methods A questionnaire-based cross-sectional survey was conducted in Pakistan among 336 pharmacies. The data were analyzed using SPSS v21 and MedCalc for Windows v12.3.0. Modified Bloom's cut-off point was utilized to categorize the participants' overall knowledge, attitude, and practice. For univariable logistic regression analyses, odds ratio (OR) was calculated at 95% confidence interval (CI). For multivariable logistic regression analyses, adjusted OR was calculated at 95% CI. Spearman's rank correlation coefficient test was used to assess the relationships among knowledge, attitude, and/or practice scores. Results The majority of the respondents were staff pharmacists (45.5%). About four-fifths (78.9%) and half (50.9%) of the participants demonstrated moderate to good knowledge and practice, respectively. However, about only one-third (33.1%) had a moderate to good attitude. Staff pharmacists had higher odds of moderate to good knowledge (OR: 2.4, 95% CI: 1.2-4.7) and practice (OR: 2.3, 95% CI: 1.4-3.8). Total knowledge and practice (Spearman's ρ: 0.280; P <0.001) and total attitude and practice (Spearman's ρ: 0.299; P <0.001) scores were significantly correlated. Conclusion The qualified pharmacists had satisfactory knowledge, attitude, and practices toward antibiotics. However, non-pharmacist staff lacked knowledge and had probable NPAD practice, which has a negative impact on public health. Regular refresher training, seminars, and strict enforcement of rules and regulations are essential.
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Affiliation(s)
- Furqan K. Hashmi
- Punjab University College of Pharmacy, University of the Punjab, Lahore, Punjab
| | - Sitaram Khadka
- Shree Birendra Hospital, Nepalese Army Institute of Health Sciences, Kathmandu
| | | | | | - Saif Ullah Khan
- Punjab University College of Pharmacy, University of the Punjab, Lahore, Punjab
| | - Hamid Saeed
- Punjab University College of Pharmacy, University of the Punjab, Lahore, Punjab
| | - Mohammad Saleem
- Punjab University College of Pharmacy, University of the Punjab, Lahore, Punjab
| | | | - Muhammad Fawad Rasool
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | | | - Zineb Riboua
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
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Boateng I, Stuart B, Becque T, Barrett B, Bostock J, Bruyndonckx R, Carr-Knox L, Ciccone EJ, Coenen S, Ebell M, Gillespie D, Hayward G, Hedin K, Hood K, Lau TMM, Little P, Merenstein D, Mulogo E, Ordóñez-Mena J, Muir P, Samuel K, Shaikh N, Tonner S, van der Velden AW, Verheij T, Wang K, Hay AD, Francis N. Using microbiological data to improve the use of antibiotics for respiratory tract infections: A protocol for an individual patient data meta-analysis. PLoS One 2023; 18:e0294845. [PMID: 38011202 PMCID: PMC10681295 DOI: 10.1371/journal.pone.0294845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Resistance to antibiotics is rising and threatens future antibiotic effectiveness. 'Antibiotic targeting' ensures patients who may benefit from antibiotics receive them, while being safely withheld from those who may not. Point-of-care tests may assist with antibiotic targeting by allowing primary care clinicians to establish if symptomatic patients have a viral, bacterial, combined, or no infection. However, because organisms can be harmlessly carried, it is important to know if the presence of the virus/bacteria is related to the illness for which the patient is being assessed. One way to do this is to look for associations with more severe/prolonged symptoms and test results. Previous research to answer this question for acute respiratory tract infections has given conflicting results with studies has not having enough participants to provide statistical confidence. AIM To undertake a synthesis of IPD from both randomised controlled trials (RCTs) and observational cohort studies of respiratory tract infections (RTI) in order to investigate the prognostic value of microbiological data in addition to, or instead of, clinical symptoms and signs. METHODS A systematic search of Cochrane Central Register of Controlled Trials, Ovid Medline and Ovid Embase will be carried out for studies of acute respiratory infection in primary care settings. The outcomes of interest are duration of disease, severity of disease, repeated consultation with new/worsening illness and complications requiring hospitalisation. Authors of eligible studies will be contacted to provide anonymised individual participant data. The data will be harmonised and aggregated. Multilevel regression analysis will be conducted to determine key outcome measures for different potential pathogens and whether these offer any additional information on prognosis beyond clinical symptoms and signs. TRIAL REGISTRATION PROSPERO Registration number: CRD42023376769.
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Affiliation(s)
- Irene Boateng
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Beth Stuart
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Taeko Becque
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Bruce Barrett
- Dept of Family Medicine, University of Wisconsin, Madison, WI, United States of America
| | - Jennifer Bostock
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Robin Bruyndonckx
- Data Science Institute, I-BioStat, Hasselt University, Martelarenlaan, Hasselt, Belgium
| | - Lucy Carr-Knox
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Emily J. Ciccone
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Mark Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States of America
| | - David Gillespie
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - Katarina Hedin
- Futurum, Region Jönköping County, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kerenza Hood
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Tin Man Mandy Lau
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Paul Little
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Dan Merenstein
- Dept of Family Medicine, Georgetown University, Washington DC, United States of America
| | - Edgar Mulogo
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jose Ordóñez-Mena
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - Peter Muir
- UK Health Security Agency South West Regional Laboratory, Southmead Hospital, Bristol, United Kingdom
| | - Kirsty Samuel
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Nader Shaikh
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Sharon Tonner
- Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kay Wang
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Alastair D. Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Nick Francis
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Little P, Francis NA, Stuart B, O'Reilly G, Thompson N, Becque T, Hay AD, Wang K, Sharland M, Harnden A, Yao G, Raftery J, Zhu S, Little J, Hookham C, Rowley K, Euden J, Harman K, Coenen S, Read RC, Woods C, Butler CC, Faust SN, Leydon G, Wan M, Hood K, Whitehurst J, Richards-Hall S, Smith P, Thomas M, Moore M, Verheij T. Antibiotics for lower respiratory tract infection in children presenting in primary care: ARTIC-PC RCT. Health Technol Assess 2023; 27:1-90. [PMID: 37436003 DOI: 10.3310/dgbv3199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background Antimicrobial resistance is a global health threat. Antibiotics are commonly prescribed for children with uncomplicated lower respiratory tract infections, but there is little randomised evidence to support the effectiveness of antibiotics in treating these infections, either overall or relating to key clinical subgroups in which antibiotic prescribing is common (chest signs; fever; physician rating of unwell; sputum/rattly chest; shortness of breath). Objectives To estimate the clinical effectiveness and cost-effectiveness of amoxicillin for uncomplicated lower respiratory tract infections in children both overall and in clinical subgroups. Design Placebo-controlled trial with qualitative, observational and cost-effectiveness studies. Setting UK general practices. Participants Children aged 1-12 years with acute uncomplicated lower respiratory tract infections. Outcomes The primary outcome was the duration in days of symptoms rated moderately bad or worse (measured using a validated diary). Secondary outcomes were symptom severity on days 2-4 (0 = no problem to 6 = as bad as it could be); symptom duration until very little/no problem; reconsultations for new or worsening symptoms; complications; side effects; and resource use. Methods Children were randomised to receive 50 mg/kg/day of oral amoxicillin in divided doses for 7 days, or placebo using pre-prepared packs, using computer-generated random numbers by an independent statistician. Children who were not randomised could participate in a parallel observational study. Semistructured telephone interviews explored the views of 16 parents and 14 clinicians, and the data were analysed using thematic analysis. Throat swabs were analysed using multiplex polymerase chain reaction. Results A total of 432 children were randomised (antibiotics, n = 221; placebo, n = 211). The primary analysis imputed missing data for 115 children. The duration of moderately bad symptoms was similar in the antibiotic and placebo groups overall (median of 5 and 6 days, respectively; hazard ratio 1.13, 95% confidence interval 0.90 to 1.42), with similar results for subgroups, and when including antibiotic prescription data from the 326 children in the observational study. Reconsultations for new or worsening symptoms (29.7% and 38.2%, respectively; risk ratio 0.80, 95% confidence interval 0.58 to 1.05), illness progression requiring hospital assessment or admission (2.4% vs. 2.0%) and side effects (38% vs. 34%) were similar in the two groups. Complete-case (n = 317) and per-protocol (n = 185) analyses were similar, and the presence of bacteria did not mediate antibiotic effectiveness. NHS costs per child were slightly higher (antibiotics, £29; placebo, £26), with no difference in non-NHS costs (antibiotics, £33; placebo, £33). A model predicting complications (with seven variables: baseline severity, difference in respiratory rate from normal for age, duration of prior illness, oxygen saturation, sputum/rattly chest, passing urine less often, and diarrhoea) had good discrimination (bootstrapped area under the receiver operator curve 0.83) and calibration. Parents found it difficult to interpret symptoms and signs, used the sounds of the child's cough to judge the severity of illness, and commonly consulted to receive a clinical examination and reassurance. Parents acknowledged that antibiotics should be used only when 'necessary', and clinicians noted a reduction in parents' expectations for antibiotics. Limitations The study was underpowered to detect small benefits in key subgroups. Conclusion Amoxicillin for uncomplicated lower respiratory tract infections in children is unlikely to be clinically effective or to reduce health or societal costs. Parents need better access to information, as well as clear communication about the self-management of their child's illness and safety-netting. Future work The data can be incorporated in the Cochrane review and individual patient data meta-analysis. Trial registration This trial is registered as ISRCTN79914298. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul Little
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Nick A Francis
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Gilly O'Reilly
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Natalie Thompson
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Taeko Becque
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Kay Wang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Michael Sharland
- Institute of Infection and Immunity, St George's University, London, UK
| | - Anthony Harnden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Guiqing Yao
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - James Raftery
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Shihua Zhu
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Joseph Little
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Charlotte Hookham
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Kate Rowley
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Joanne Euden
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Kim Harman
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Samuel Coenen
- Department of Family Medicine & Population Health and Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Robert C Read
- National Institute for Health and Care Research (NIHR) Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Catherine Woods
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Saul N Faust
- National Institute for Health and Care Research (NIHR) Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Geraldine Leydon
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Mandy Wan
- Evelina Pharmacy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kerenza Hood
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Jane Whitehurst
- National Institute for Health and Care Research (NIHR) Applied Research Collaboration West Midlands, Coventry, UK
| | - Samantha Richards-Hall
- Southampton Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Peter Smith
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Michael Thomas
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Theo Verheij
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
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9
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Cannon JW, Wyber R. Modalities of group A streptococcal prevention and treatment and their economic justification. NPJ Vaccines 2023; 8:59. [PMID: 37087467 PMCID: PMC10122086 DOI: 10.1038/s41541-023-00649-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 03/23/2023] [Indexed: 04/24/2023] Open
Abstract
Infection by group A Streptococcus (Strep A) results in a diverse range of clinical conditions, including pharyngitis, impetigo, cellulitis, necrotising fasciitis, and rheumatic heart disease. In this article, we outline the recommended strategies for Strep A treatment and prevention and review the literature for economic evaluations of competing treatment and prevention strategies. We find that most economic evaluations focus on reducing the duration of illness or risk of rheumatic fever among people presenting with sore throat through diagnostic and/or treatment strategies. Few studies have evaluated strategies to reduce the burden of Strep A infection among the general population, nor have they considered the local capacity to finance and implement strategies. Evaluation of validated costs and consequences for a more diverse range of Strep A interventions are needed to ensure policies maximise patient outcomes under budget constraints. This should include attention to basic public health strategies and emerging strategies such as vaccination.
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Affiliation(s)
- Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia.
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Rosemary Wyber
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia
- National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, National Centre for Epidemiology and Population Health, ANU College of Health & Medicine, The Australian National University, Canberra, Australia
- Adjunct Senior Research Fellow, University of Western Australia, Nedlands, WA, Australia
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10
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Wächtler H, Kaduszkiewicz H, Kuhnert O, Malottki KA, Maaß S, Hedderich J, Wiese B, Donner-Banzhoff N, Hansmann-Wiest J. 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). BMC PRIMARY CARE 2023; 24:75. [PMID: 36941540 PMCID: PMC10029262 DOI: 10.1186/s12875-023-01987-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 01/18/2023] [Indexed: 03/22/2023]
Abstract
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.
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Affiliation(s)
- Hannelore Wächtler
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | - Hanna Kaduszkiewicz
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany.
| | - Oskar Kuhnert
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | | | - Sonja Maaß
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
| | - Jürgen Hedderich
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus V40, 24105, Kiel, Germany
| | - Birgitt Wiese
- IT Services Applications, Science & Laboratory, MHH Information Technology, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Julia Hansmann-Wiest
- Institute of General Practice, Kiel University, Michaelisstr. 5, 24105, Kiel, Germany
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11
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Della Bella C, Corrà A, Mantengoli E, Galano A, Benagiano M, Bonciani D, Mariotti EB, Pratesi S, Quintarelli L, Aimo C, Grassi A, D'Elios S, Volpi W, Verdelli A, Bartoloni A, Rossolini GM, D'Elios MM, Caproni M. Skin IL-17A and IFN-γ Production Correlate with Disease Severity in Patients with Psoriasis and Streptococcal Infection. J Invest Dermatol 2023; 143:925-932. [PMID: 36642401 DOI: 10.1016/j.jid.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 01/15/2023]
Abstract
Psoriasis is a multisystemic inflammatory disorder mainly involving the skin and joints, whose etiopathogenesis is still not completely understood. An association with streptococcal throat infection has been suggested. We aim to investigate a correlation between IL-17A and IFN-γ production by T cells infiltrating skin lesions and PASI in 313 patients with psoriasis, compared with that in 252 healthy controls. The phenotype of β-hemolytic Streptococci-specific infiltrating T cells in skin lesions was evaluated and characterized for IFN-γ, IL-4, and IL-17A production. In addition, PBMCs were tested by ELISpot for IFN-γ and IL-17A after streptococcal antigen exposure. A total of 64 of 313 (20.4%) patients with psoriasis had throat streptococcal infection. Of the 3,868 skin-derived T-cell clones from psoriasis with streptococcal infection, 66% proliferated in response to β-hemolytic Streptococci antigens. Most β-hemolytic Streptococci-specific T cells displayed T helper 17 and T helper 1 phenotypes. The levels of IFN-γ and IL-17A secreted by skin-infiltrating T cells of patients with psoriasis significantly correlated with PASI score. In β-hemolytic Streptococci-positive patients, IFN-γ and IL-17A production by peripheral blood T cells after stimulation with streptococcal antigens was quantified by ELISpot. The results obtained may suggest ELISpot as a useful diagnostic tool to identify patients with psoriasis that may deserve antibiotic treatment.
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Affiliation(s)
- Chiara Della Bella
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Alberto Corrà
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Angelo Galano
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Marisa Benagiano
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | | | - Sara Pratesi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lavinia Quintarelli
- Immunopathology and Rare Skin Diseases Unit, Section of Dermatology, Department of Health Sciences, Azienda Unità Sanitaria Locale Toscana Centro, University of Florence, Florence, Italy
| | - Cristina Aimo
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Alessia Grassi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sofia D'Elios
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Walter Volpi
- Immunopathology and Rare Skin Diseases Unit, Section of Dermatology, Department of Health Sciences, Azienda Unità Sanitaria Locale Toscana Centro, University of Florence, Florence, Italy
| | - Alice Verdelli
- Immunopathology and Rare Skin Diseases Unit, Section of Dermatology, Department of Health Sciences, Azienda Unità Sanitaria Locale Toscana Centro, University of Florence, Florence, Italy
| | - Alessandro Bartoloni
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Mario Milco D'Elios
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Marzia Caproni
- Immunopathology and Rare Skin Diseases Unit, Section of Dermatology, Department of Health Sciences, Azienda Unità Sanitaria Locale Toscana Centro, University of Florence, Florence, Italy.
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12
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Rutkovska I, Linde-Ozola Z, Poplavska E. Role of multidimensional factors in the diagnosis and treatment of tonsillopharyngitis in primary care: a qualitative study. BMC PRIMARY CARE 2022; 23:275. [PMID: 36333657 PMCID: PMC9635145 DOI: 10.1186/s12875-022-01881-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
Background Tonsillopharyngitis is one of the most frequently observed upper respiratory tract infections, for which antibiotics are prescribed in ambulatory care. In most cases, tonsillopharyngitis is benign and self-limiting, mostly a viral condition. The aim of this study was to explore the diagnostic and treatment process of tonsillopharyngitis by general practitioners and to understand decisions regarding antibiotic prescribing and the factors that shape these practices. Methods/design This was a qualitative interview study in primary care practices in Latvia. Semi-structured face-to-face interviews were conducted with general practitioners from November 2016 to January 2017. Thematic analysis was applied to identify factors that influence the prescribing practice in a primary care setting in conjunction with a specific context in which the prescriber practices. Results Decisions and practice of general practitioner are not static over time or context; they occur within an environmental setting influenced by individual factors of general practitioners, the health care system, and practice-specific factors that shape the diagnosis and antibiotic prescribing in the tonsillopharyngitis. Interviewed general practitioners rely primarily on their personal experience, perception, and skills acquired in their practice, which are encouraged by the environment, where the necessary tools and resources are not in place to encourage rational prescribing of antibiotics. Conclusions General practitioners’ decision regarding antibiotic prescribing is an unstable concept that differs between prescribers. The health care system could augment the experience of general practitioners through structural changes such as guidelines, availability of antibiotics, and available antibiotics package size.
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Affiliation(s)
- Ieva Rutkovska
- grid.17330.360000 0001 2173 9398Department of Applied Pharmacy, Faculty of Pharmacy, Riga Stradiņš University, Riga, Latvia
| | - Zane Linde-Ozola
- grid.9845.00000 0001 0775 3222Department of Anthropology, Faculty of Humanities, University of Latvia, Riga, Latvia
| | - Elita Poplavska
- grid.17330.360000 0001 2173 9398Department of Applied Pharmacy, Faculty of Pharmacy, Riga Stradiņš University, Riga, Latvia ,grid.17330.360000 0001 2173 9398Institute of Public Health, Riga Stradiņš University, Riga, Latvia
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13
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Smedemark SA, Aabenhus R, Llor C, Fournaise A, Olsen O, Jørgensen KJ. Biomarkers as point-of-care tests to guide prescription of antibiotics in people with acute respiratory infections in primary care. Cochrane Database Syst Rev 2022; 10:CD010130. [PMID: 36250577 PMCID: PMC9575154 DOI: 10.1002/14651858.cd010130.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. It follows that in many cases antibiotic use will not be beneficial to a patient's recovery but may expose them to potential side effects. Furthermore, limiting unnecessary antibiotic use is a key factor in controlling antibiotic resistance. One strategy to reduce antibiotic use in primary care is point-of-care biomarkers. A point-of-care biomarker (test) of inflammation identifies part of the acute phase response to tissue injury regardless of the aetiology (infection, trauma, or inflammation) and may be used as a surrogate marker of infection, potentially assisting the physician in the clinical decision whether to use an antibiotic to treat ARIs. Biomarkers may guide antibiotic prescription by ruling out a serious bacterial infection and help identify patients in whom no benefit from antibiotic treatment can be anticipated. This is an update of a Cochrane Review first published in 2014. OBJECTIVES To assess the benefits and harms of point-of-care biomarker tests of inflammation to guide antibiotic treatment in people presenting with symptoms of acute respiratory infections in primary care settings regardless of patient age. SEARCH METHODS We searched CENTRAL (2022, Issue 6), MEDLINE (1946 to 14 June 2022), Embase (1974 to 14 June 2022), CINAHL (1981 to 14 June 2022), Web of Science (1955 to 14 June 2022), and LILACS (1982 to 14 June 2022). We also searched three trial registries (10 December 2021) for completed and ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared the use of point-of-care biomarkers with standard care. We included trials that randomised individual participants, as well as trials that randomised clusters of patients (cluster-RCTs). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on the following primary outcomes: number of participants given an antibiotic prescription at index consultation and within 28 days follow-up; participant recovery within seven days follow-up; and total mortality within 28 days follow-up. We assessed risk of bias using the Cochrane risk of bias tool and the certainty of the evidence using GRADE. We used random-effects meta-analyses when feasible. We further analysed results with considerable heterogeneity in prespecified subgroups of individual and cluster-RCTs. MAIN RESULTS We included seven new trials in this update, for a total of 13 included trials. Twelve trials (10,218 participants in total, 2335 of which were children) evaluated a C-reactive protein point-of-care test, and one trial (317 adult participants) evaluated a procalcitonin point-of-care test. The studies were conducted in Europe, Russia, and Asia. Overall, the included trials had a low or unclear risk of bias. However all studies were open-labelled, thereby introducing high risk of bias due to lack of blinding. The use of C-reactive protein point-of-care tests to guide antibiotic prescription likely reduces the number of participants given an antibiotic prescription, from 516 prescriptions of antibiotics per 1000 participants in the control group to 397 prescriptions of antibiotics per 1000 participants in the intervention group (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.69 to 0.86; 12 trials, 10,218 participants; I² = 79%; moderate-certainty evidence). Overall, use of C-reactive protein tests also reduce the number of participants given an antibiotic prescription within 28 days follow-up (664 prescriptions of antibiotics per 1000 participants in the control group versus 538 prescriptions of antibiotics per 1000 participants in the intervention group) (RR 0.81, 95% CI 0.76 to 0.86; 7 trials, 5091 participants; I² = 29; high-certainty evidence). The prescription of antibiotics as guided by C-reactive protein tests likely does not reduce the number of participants recovered, within seven or 28 days follow-up (567 participants recovered within seven days follow-up per 1000 participants in the control group versus 584 participants recovered within seven days follow-up per 1000 participants in the intervention group) (recovery within seven days follow-up: RR 1.03, 95% CI 0.96 to 1.12; I² = 0%; moderate-certainty evidence) (recovery within 28 days follow-up: RR 1.02, 95% CI 0.79 to 1.32; I² = 0%; moderate-certainty evidence). The use of C-reactive protein tests may not increase total mortality within 28 days follow-up, from 1 death per 1000 participants in the control group to 0 deaths per 1000 participants in the intervention group (RR 0.53, 95% CI 0.10 to 2.92; I² = 0%; low-certainty evidence). We are uncertain as to whether procalcitonin affects any of the primary or secondary outcomes because there were few participants, thereby limiting the certainty of evidence. We assessed the certainty of the evidence as moderate to high according to GRADE for the primary outcomes for C-reactive protein test, except for mortality, as there were very few deaths, thereby limiting the certainty of the evidence. AUTHORS' CONCLUSIONS The use of C-reactive protein point-of-care tests as an adjunct to standard care likely reduces the number of participants given an antibiotic prescription in primary care patients who present with symptoms of acute respiratory infection. The use of C-reactive protein point-of-care tests likely does not affect recovery rates. It is unlikely that further research will substantially change our conclusion regarding the reduction in number of participants given an antibiotic prescription, although the size of the estimated effect may change. The use of C-reactive protein point-of-care tests may not increase mortality within 28 days follow-up, but there were very few events. Studies that recorded deaths and hospital admissions were performed in children from low- and middle-income countries and older adults with comorbidities. Future studies should focus on children, immunocompromised individuals, and people aged 80 years and above with comorbidities. More studies evaluating procalcitonin and potential new biomarkers as point-of-care tests used in primary care to guide antibiotic prescription are needed. Furthermore, studies are needed to validate C-reactive protein decision algorithms, with a specific focus on potential age group differences.
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Affiliation(s)
- Siri Aas Smedemark
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- Research Unit of General Practice, Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
| | - Anders Fournaise
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cross-sectoral Collaboration, Region of Southern Denmark, Vejle, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ole Olsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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14
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Mantzourani E, Cannings-John R, Evans A, Ahmed H. To swab or not to swab? Using point-of-care tests to detect Group A Streptococcus infections as part of a Sore Throat Test and Treat service in community pharmacy. J Antimicrob Chemother 2022; 77:803-806. [PMID: 35038341 PMCID: PMC8865000 DOI: 10.1093/jac/dkab470] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/12/2021] [Indexed: 11/15/2022] Open
Abstract
Background The community pharmacy-led Sore Throat Test and Treat (STTT) service in Wales allowed pharmacists to undertake a structured clinical assessment with FeverPAIN/Centor scores and a point-of-care test (POCT) for Group A Streptococcus (GAS) infection. A new service model was temporarily agreed as a result of COVID-19, without routine use of POCT. Objectives To explore the impact of removing the requirement for GAS POCT from a community pharmacy STTT service on antibiotic supply. Methods Analysis of STTT consultation data, obtained for two periods: November 2018 (date the service went live) to September 2019 (pre-pandemic); and November 2020 (date the new service model was introduced) to May 2021. Results For consultations eligible for POCT, the antibiotic supply rate increased from 27% (922/3369) (95% CI: 26%–29%) with the pre-pandemic service model (FeverPAIN/Centor + POCT) to 63% (93/147) (95% CI: 55%–71%) with the new model (FeverPAIN/Centor only); the percentage of patients who were not issued an antibiotic, despite their high clinical score, decreased from 56% (646/1154) to 9.3% (8/86). Conclusions Preliminary data suggest that for every 100 STTT consultations with patients with a Centor score of ≥3 or a FeverPAIN score of ≥2, the use of POCT may spare up to 36 courses of antibiotics, increasing to 47 for patients with higher clinical scores, suggesting that the pre-COVID delivery model (FeverPAIN/Centor + POCT) is the optimal pathway and POCT in addition to clinical scores may result in fewer antibiotic prescriptions for sore throat symptoms. These findings have implications for STTT service delivery during and beyond the COVID-19 pandemic.
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Affiliation(s)
- Efi Mantzourani
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, Wales, UK.,Digital Health and Care Wales, NHS Wales, Cardiff, Wales, UK
| | | | - Andrew Evans
- Primary Care Services, Welsh Government, Cardiff, Wales, UK
| | - Haroon Ahmed
- Division of Population Medicine, Cardiff University, Cardiff, Wales, UK
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15
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Miron VD, Craiu M. "Red throat" or acute pharyngitis - challenges in real life clinical practice. Germs 2021; 11:351-353. [PMID: 34722356 DOI: 10.18683/germs.2021.1271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Victor Daniel Miron
- MD, PhD student, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, National Institute for Mother and Child Health "Alessandrescu-Rusescu”, Bd Lacul Tei 120, Bucharest, Romania
| | - Mihai Craiu
- MD, PhD, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, National Institute for Mother and Child Health "Alessandrescu-Rusescu”, Bd Lacul Tei 120, Bucharest, Romania
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16
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Miron VD, Bar G, Filimon C, Gaidamut VA, Craiu M. Streptococcal Pharyngitis in Children: A Tertiary Pediatric Hospital in Bucharest, Romania. J Glob Infect Dis 2021; 13:154-155. [PMID: 34703159 PMCID: PMC8491814 DOI: 10.4103/jgid.jgid_59_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Victor Daniel Miron
- Department of Pediatrics, National Institute for Mother and Child Health "Alessandrescu-Rusescu", Bucharest, Romania.,Faculty of Medicine, Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gabriela Bar
- Department of Pediatrics, National Institute for Mother and Child Health "Alessandrescu-Rusescu", Bucharest, Romania
| | - Claudiu Filimon
- Faculty of Medicine, General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Vlad Alexandru Gaidamut
- Faculty of Medicine, General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihai Craiu
- Department of Pediatrics, National Institute for Mother and Child Health "Alessandrescu-Rusescu", Bucharest, Romania.,Faculty of Medicine, Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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17
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Fraser H, Gallacher D, Achana F, Court R, Taylor-Phillips S, Nduka C, Stinton C, Willans R, Gill P, Mistry H. Rapid antigen detection and molecular tests for group A streptococcal infections for acute sore throat: systematic reviews and economic evaluation. Health Technol Assess 2021; 24:1-232. [PMID: 32605705 DOI: 10.3310/hta24310] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Sore throat is a common condition caused by an infection of the airway. Most cases are of a viral nature; however, a number of these infections may be caused by the group A Streptococcus bacterium. Most viral and bacterial sore throat infections resolve spontaneously within a few weeks. Point-of-care testing in primary care has been recognised as an emerging technology for aiding targeted antibiotic prescribing for sore throat in cases that do not spontaneously resolve. OBJECTIVE Systematically review the evidence for 21 point-of-care tests for detecting group A Streptococcus bacteria and develop a de novo economic model to compare the cost-effectiveness of point-of-care tests alongside clinical scoring tools with the cost-effectiveness of clinical scoring tools alone for patients managed in primary care and hospital settings. DATA SOURCES Multiple electronic databases were searched from inception to March 2019. The following databases were searched in November and December 2018 and searches were updated in March 2019: MEDLINE [via OvidSP (Health First, Rockledge, FL, USA)], MEDLINE In-Process & Other Non-Indexed Citations (via OvidSP), MEDLINE Epub Ahead of Print (via OvidSP), MEDLINE Daily Update (via OvidSP), EMBASE (via OvidSP), Cochrane Database of Systematic Reviews [via Wiley Online Library (John Wiley & Sons, Inc., Hoboken, NJ, USA)], Cochrane Central Register of Controlled Trials (CENTRAL) (via Wiley Online Library), Database of Abstracts of Reviews of Effects (DARE) (via Centre for Reviews and Dissemination), Health Technology Assessment database (via the Centre for Reviews and Dissemination), Science Citation Index and Conference Proceedings [via the Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA)] and the PROSPERO International Prospective Register of Systematic Reviews (via the Centre for Reviews and Dissemination). REVIEW METHODS Eligible studies included those of people aged ≥ 5 years presenting with sore throat symptoms, studies comparing point-of-care testing with antibiotic-prescribing decisions, studies of test accuracy and studies of cost-effectiveness. Quality assessment of eligible studies was undertaken. Meta-analysis of sensitivity and specificity was carried out for tests with sufficient data. A decision tree model estimated costs and quality-adjusted life-years from an NHS and Personal Social Services perspective. RESULTS The searches identified 38 studies of clinical effectiveness and three studies of cost-effectiveness. Twenty-six full-text articles and abstracts reported on the test accuracy of point-of-care tests and/or clinical scores with biological culture as a reference standard. In the population of interest (patients with Centor/McIsaac scores of ≥ 3 points or FeverPAIN scores of ≥ 4 points), point estimates were 0.829 to 0.946 for sensitivity and 0.849 to 0.991 for specificity. There was considerable heterogeneity, even for studies using the same point-of-care test, suggesting that is unlikely that any single study will have accurately captured a test's true performance. There is some randomised controlled trial evidence to suggest that the use of rapid antigen detection tests may help to reduce antibiotic-prescribing rates. Sensitivity and specificity estimates for each test in each age group and care setting combination were obtained using meta-analyses where appropriate. Any apparent differences in test accuracy may not be attributable to the tests, and may have been caused by known differences in the studies, latent characteristics or chance. Fourteen of the 21 tests reviewed were included in the economic modelling, and these tests were not cost-effective within the current National Institute for Health and Care Excellence's cost-effectiveness thresholds. Uncertainties in the cost-effectiveness estimates included model parameter inputs and assumptions that increase the cost of testing, and the penalty for antibiotic overprescriptions. LIMITATIONS No information was identified for the elderly population or pharmacy setting. It was not possible to identify which test is the most accurate owing to the paucity of evidence. CONCLUSIONS The systematic review and the cost-effectiveness models identified uncertainties around the adoption of point-of-care tests in primary and secondary care settings. Although sensitivity and specificity estimates are promising, we have little information to establish the most accurate point-of-care test. Further research is needed to understand the test accuracy of point-of-care tests in the proposed NHS pathway and in comparable settings and patient groups. STUDY REGISTRATION The protocol of the review is registered as PROSPERO CRD42018118653. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 31. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hannah Fraser
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Felix Achana
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Chidozie Nduka
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Chris Stinton
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Paramjit Gill
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Warwick Medical School, University of Warwick, Coventry, UK
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Qian Y, Walters SJ, Jacques R, Flight L. Comprehensive review of statistical methods for analysing patient-reported outcomes (PROs) used as primary outcomes in randomised controlled trials (RCTs) published by the UK's Health Technology Assessment (HTA) journal (1997-2020). BMJ Open 2021; 11:e051673. [PMID: 34489292 PMCID: PMC8422492 DOI: 10.1136/bmjopen-2021-051673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To identify how frequently patient-reported outcomes (PROs) are used as primary and/or secondary outcomes in randomised controlled trials (RCTs) and to summarise what statistical methods are used for the analysis of PROs. DESIGN Comprehensive review. SETTING RCTs funded and published by the United Kingdom's (UK) National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme. DATA SOURCES AND ELIGIBILITY HTA reports of RCTs published between January 1997 and December 2020 were reviewed. DATA EXTRACTION Information relating to PRO use and analysis methods was extracted. PRIMARY AND SECONDARY OUTCOME MEASURES The frequency of using PROs as primary and/or secondary outcomes; statistical methods that were used for the analysis of PROs as primary outcomes. RESULTS In this review, 37.6% (114/303) of trials used PROs as primary outcomes, and 82.8% (251/303) of trials used PROs as secondary outcomes from 303 NIHR HTA reports of RCTs. In the 114 RCTs where the PRO was the primary outcome, the most used PRO was the Short-Form 36 (8/114); the most popular methods for multivariable analysis were linear mixed model (45/114), linear regression (29/114) and analysis of covariance (13/114); logistic regression was applied for binary and ordinal outcomes in 14/114 trials; and the repeated measures analysis was used in 39/114 trials. CONCLUSION The majority of trials used PROs as primary and/or secondary outcomes. Conventional methods such as linear regression are widely used, despite the potential violation of their assumptions. In recent years, there is an increasing trend of using complex models (eg, with mixed effects). Statistical methods developed to address these violations when analysing PROs, such as beta-binomial regression, are not routinely used in practice. Future research will focus on evaluating available statistical methods for the analysis of PROs.
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Affiliation(s)
- Yirui Qian
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Richard Jacques
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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19
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Lee JS, Kim S, Excler JL, Kim J, Mogasale V. Existing cost-effectiveness analyses for diseases caused by Group A Streptococcus: A systematic review to guide future research. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.17116.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Group A Streptococcus (Strep A) causes a broad spectrum of disease manifestations, ranging from benign symptoms including throat or skin infections, to fatal illness such as rheumatic heart disease, or chronic renal failure. Currently, there is no vaccine available against Strep A infections. Despite the high burden of Strep A-associated infections worldwide, little attention has been paid to the research of these diseases, including standardized surveillance programs, resulting in a lack of economic evaluations for prevention efforts. This study aims at identifying existing cost-effectiveness analyses (CEA) on any Strep A infections. Methods: A systematic literature review was conducted by searching the PubMed electronic database. Results: Of a total of 321, 44 articles met the criteria for inclusion. Overall, CEA studies on Strep A remain limited in number. In particular, a number of available CEA studies on Strep A are disproportionately lower in low-income countries than in high-income countries. Decision-analytic models were the most popular choice for CEA on Strep A. A majority of the models considered pharyngitis and acute rheumatic fever, but it was rare to observe a model which covered a wide range of disease manifestations. Conclusions: Future research is needed to address missing clinical outcomes, imbalance on study locations by income group, and the transmission dynamic of selected diseases.
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20
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Heggie R, Boyd K, Wu O. How has implementation been incorporated in health technology assessments in the United Kingdom? A systematic rapid review. Health Res Policy Syst 2021; 19:118. [PMID: 34407834 PMCID: PMC8371806 DOI: 10.1186/s12961-021-00766-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/26/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Health interventions in a clinical setting may be complex. This is particularly true of clinical interventions which require systems reorganization or behavioural change, and/or when implementation involves additional challenges not captured within a clinical trial setting. Medical Research Council guidance on complex interventions highlights the need to consider economic evaluation alongside implementation. However, the extent to which this guidance has been adhered to, and how, is unclear. The failure to incorporate implementation within the evaluation of an intervention may hinder the translation of research findings into routine practice. This will have consequences for patient care. This study examined the methods used to address implementation within health research conducted through funding from the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme. METHODS We conducted a rapid review using a systematic approach. We included all NIHR HTA monographs which contained the word "implementation" within the title or abstract published between 2014 and 2020. We assessed the studies according to existing recommendations for specifying and reporting implementation approaches in research. Additional themes which were not included in the recommendation, but were of particular relevance to our research question, were also identified and summarized in a narrative synthesis. RESULTS The extent to which implementation was formally incorporated, and defined, varied among studies. Methods for examining implementation ranged from single stakeholder engagement events to the more comprehensive process evaluation. There was no obvious pattern as to whether approaches to implementation had evolved over recent years. Approximately 50% (22/42) of studies included an economic evaluation. Of these, two studies included the use of qualitative data obtained within the study to quantitatively inform aspects relating to implementation and economic evaluation in their study. DISCUSSION A variety of approaches were identified for incorporating implementation within an HTA. However, they did not go far enough in terms of incorporating implementation into the actual design and evaluation. To ensure the implementation of clinically effective and cost-effective interventions, we propose that further guidance on how to incorporate implementation within complex interventions is required. Incorporating implementation into economic evaluation provides a step in this direction.
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Affiliation(s)
- Robert Heggie
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - Kathleen Boyd
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
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21
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Pernica JM, Smaill F, Kam AJ, Bartholomew A, Doan Q, Smieja M, Khan S, Sung M, Thabane L, Goldfarb DM. Single-centre, open-label, randomised, trial to compare rapid molecular point-of-care streptococcal testing to standard laboratory-based testing for the management of streptococcal pharyngitis in children: study protocol. BMJ Open 2021; 11:e047271. [PMID: 34380724 PMCID: PMC8359528 DOI: 10.1136/bmjopen-2020-047271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Streptococcal pharyngitis, which commonly occurs in children, should be treated with antibiotics. Clinical prediction rules to differentiate streptococcal pharyngitis from viral infection are not recommended in children. Rapid point-of-care (POC) antigen tests have limited sensitivity and so are not often used in Canadian paediatric emergency departments (EDs). Standard paediatric practice is to rely on laboratory-based testing, which often results in a delay before the results can be communicated to the patient; this may impede appropriate prescribing, decrease caregiver satisfaction and delay recovery. The objective of this study is to determine whether a novel rapid molecular POC assay for streptococcal pharyngitis leads to more appropriate antibiotic use in children seeking care in a paediatric ED than standard laboratory-based testing. METHODS AND ANALYSIS A randomised, superiority, open-label, trial with two parallel groups. Children presenting to a tertiary paediatric ED at least 3 years of age who have a throat swab ordered for diagnosis of streptococcal pharyngitis will be eligible; those who have taken antibiotics within 72 hours prior to presentation and those with additional active infections will be excluded. The primary study outcome will be appropriate antibiotic treatment at 3-5 days postenrolment. Secondary outcomes include time to symptom resolution, caregiver satisfaction, caregiver/child absenteeism, number of subsequent healthcare visits, clinician satisfaction and incremental cost-effectiveness of POC testing. A total of 352 participants will be needed. ETHICS AND DISSEMINATION All study documentation has been approved by the Hamilton Integrated Research Ethics board and informed consent will be obtained from all participants. Data from this trial will be presented at major conferences and published in peer-reviewed publications to facilitate collaborations with networks of clinicians experienced in the dissemination of clinical guidelines. TRIAL REGISTRATION NUMBER NCT04247243.
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Affiliation(s)
- Jeffrey M Pernica
- Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Fiona Smaill
- Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - April J Kam
- Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Amy Bartholomew
- Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Quynh Doan
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marek Smieja
- Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Khan
- Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Melani Sung
- Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - David M Goldfarb
- Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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22
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Hu YJ, Zhou X, Wang S, Willcox M, Garner C, Brown D, Becque T, Stuart B, Han Z, Chang Q, Moore M, Little P. Diarrhoea Management using Over-the-counter Nutraceuticals in Daily practice (DIAMOND): a feasibility RCT on alternative therapy to reduce antibiotic use. Pilot Feasibility Stud 2021; 7:126. [PMID: 34130752 PMCID: PMC8204461 DOI: 10.1186/s40814-021-00850-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although rarely indicated, antibiotics are commonly used for acute diarrhoea in China. We conducted a randomised, double blind exploratory clinical trial of loperamide, berberine and turmeric for treatment of acute diarrhoea. METHODS Adults with acute uncomplicated diarrhoea aged 18 to 70 were randomised to 4 groups: (A) loperamide; (B) loperamide and berberine; (C) loperamide and turmeric; (D) loperamide, berberine and turmeric. All participants were given rescue ciprofloxacin for use after 48 h if symptoms worsened or were unimproved. Primary endpoints were feasibility and ciprofloxacin use during the 2-week follow-up period. Semi-structured interviews were conducted following recruitment and were analysed thematically. Recruiting doctors, delivery pharmacists and research assistants were blinded to treatment allocation. RESULTS Only 21.5% (278/1295) of patients screened were deemed eligible, and 49% (136/278) of these consented and were entered into the final analysis. Most participants had mild symptoms, because most patients with moderate or severe symptoms wanted to be given antibiotics. Follow-up was good (94% at 2 weeks). Only three participants used rescue antibiotics compared to 67% of acute diarrhoea patients in the hospital during the recruitment period. The median symptom duration was 14 h in group B (interquartile range (IQR) 10-22), 16 h in group D (IQR 10-22), 18 h in group A (IQR 10-33) and 20 h in group C (IQR 16-54). Re-consultation rates were low. There were no serious treatment-related adverse events. Most interviewed participants said that although they had believed antibiotics to be effective for diarrhoea, they were surprised by their quick recovery without antibiotics in this trial. CONCLUSION Although recruitment was challenging because of widespread expectations for antibiotics, patients with mild diarrhoea accepted trying an alternative. The three nutraceuticals therapy require further evaluation in a fully powered, randomised controlled trial among a broader sample. TRIAL REGISTRATION ChiCTR-IPR-17014107.
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Affiliation(s)
- Yanhong Jessika Hu
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia. .,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.
| | - Xudong Zhou
- School of Public Health, Zhejiang University, 866 Yuhangtang Road, Zhejiang, 310058, Hangzhou, China
| | - Shanjuan Wang
- Affiliated Hospital of Jiading District Centre, Shanghai Institute of Health Science, No. 1 Chengbei Rd, Jiading Qu, Shanghai Shi, 201800, China
| | - Merlin Willcox
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Colin Garner
- Antibiotic Research UK, Genesis 5, York Science Park, Heslington, York, YO10 5DQ, United Kingdom
| | - David Brown
- Alchemy Biomedical Consulting, St Johns Innovation Centre, Cowley Road, Cambridge, CB4 0WS, United Kingdom
| | - Taeko Becque
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Beth Stuart
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Zongru Han
- Affiliated Hospital of Jiading District Centre, Shanghai Institute of Health Science, No. 1 Chengbei Rd, Jiading Qu, Shanghai Shi, 201800, China
| | - Qin Chang
- Affiliated Hospital of Jiading District Centre, Shanghai Institute of Health Science, No. 1 Chengbei Rd, Jiading Qu, Shanghai Shi, 201800, China
| | - Michael Moore
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Paul Little
- Primary Care Research Centre, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
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23
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Krüger K, Töpfner N, Berner R, Windfuhr J, Hendrik Oltrogge J. Clinical Practice Guideline: Sore Throat. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:188-94. [PMID: 33602392 PMCID: PMC8245861 DOI: 10.3238/arztebl.m2021.0121] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Sore throat is a common reason for consultation of primary care physicians, pediatricians, and ENT specialists. The updated German clinical practice guideline on sore throat provides evidence-based recommendations for treatment in the German healthcare system. METHODS Guideline revision by means of a systematic search of the literature for international guidelines and systematic reviews. All recommendations resulted from interdisciplinary cooperation and were agreed by formal consensus. The updated guideline applies to patients aged 3 years and over. RESULTS In the absence of red flags such as immunosuppression, severe comorbidity, or severe systemic infection, acute sore throat is predominantly self-limiting. The mean duration is 7 days. Chronic sore throat usually has noninfectious causes. Laboratory tests are not routinely necessary. Apart from non-pharmacological self-management, ibuprofen and naproxen are recommended for symptomatic treatment. Scores can be used to assess the risk of bacterial pharyngitis: one point each is assigned for tonsil lesions, palpable cervical lymph nodes, patient age, disease course, and elevated temperature. If the risk is low (<3 points), antibiotics are not indicated; if at least moderate (3 points), delayed prescribing is recommended; if high (>3 points), antibiotics can be taken immediately. Penicillin remains the first choice, with clarithromycin as an alternative for those who do not tolerate penicillin. The antibiotic should be taken for 5-7 days. CONCLUSION After the exclusion of red flags, antibiotic treatment is unnecessary in many cases of acute sore throat. If administration of antibiotics is still considered in spite of consultation on the usual course of tonsillopharyngitis and the low risk of complications, a risk-adapted approach using clinical scores is recommended.
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Affiliation(s)
- Karen Krüger
- Institute of General Practice and Family Medicine, Charité—Universitätsmedizin Berlin
| | - Nicole Töpfner
- Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden
| | - Reinhard Berner
- Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden
| | - Jochen Windfuhr
- Department of Otolaryngology, Kliniken Maria Hilf Mönchengladbach
| | - Jan Hendrik Oltrogge
- Department of General Practice and Primary Care, Hamburg University Medical School, Universitätsklinikum Hamburg-Eppendorf (UKE)
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24
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Meskina ER, Stashko TV. [How to reduce the antibacterial load in the treatment of acute tonsillitis and pharyngitis? Possible tactics and practical approaches]. Vestn Otorinolaringol 2021; 85:90-99. [PMID: 33474925 DOI: 10.17116/otorino20208506190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute tonsillopharyngitis is one of the most frequent reasons for visiting a doctor and prescribing inappropriate antibiotic therapy (ABT). There are several reasons for this - from the difficulties of etiological diagnosis and the development of relapses and possible severe complications to the personal attitude of doctors and patients to the choice of treatment. At the same time, the issue of antibiotic resistance and other aspects associated with the prescription of ABT is one of the most important problems of modern healthcare worldwide. The purpose of this review is to demonstrate the best practical approaches to the choice of treatment tactics for acute tonsillitis (AT) in the treatment of children and adults, with an emphasis on reducing the load of ABT. The review examines the indications and disadvantages of clinical and laboratory diagnosis of AT. There are no highly sensitive clinical and laboratory instruments that differentiate viral and bacterial AT. Exudativeis AT in children is not an underlying symptom of streptococcal etiology. Despite the limitations, the modified Centor/McIsaac score ≥3 (taking into account age and the presence of respiratory symptoms) should be used as an indication for ABT in conjunction with a rapid streptotest and subsequent bacteriological culture for S. pyogenes if the screening test is negative. Additional examinations (determination of leukocytosis, CRP and procalcitonin test) are not required for most patients. ABT should not be given to low-risk patients for the treatment and prevention of rheumatic fever and acute glomerulonephritis. Prevention of purulent complications (paratonsillitis and retropharyngeal abscess, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis) is not a specific indication for ABT in AT and is not required in most patients. The strategy of «delayed antibiotic prescriptions» with monitoring the patient's condition for 2-3 days is appropriate and highly effective in doubtful cases. The drugs of choice for treatment of AT are amoxicillin and oral forms of I and II generation cephalosporins. Macrolides are not indicated as first-line treatment for AT. The course of ABT for streptococcal AT is 10 days, which reduces the risk of recurrent episode. Topical drugs can be the only means of etiopathogenetic treatment with viral AT, or additional for bacterial AT. Their use not only relieves sore throat, but also shortens the duration of the disease, and also improves the patients prognosis. Benzalkonium chloride + tyrothricin + benzocaine (Dorithyrcin) may be a rational drug of choice for topical therapy due to the available clinical evidence. There is a significant reserve for reducing the load of ABT during AT. Further clinical trials are needed to assess the efficacy of short courses of ABT in the treatment of AT in high-income countries and provide a basis for strong recommendations for topical drug use. This can reduce the frequency of ABT prescribing and increase the level of interaction between specialists and patients.
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Affiliation(s)
- E R Meskina
- Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia
| | - T V Stashko
- Moscow Regional Research and Clinical Institute (MONIKI), Moskow, Russia
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25
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Morrell L, Buchanan J, Roope LSJ, Pouwels KB, Butler CC, Hayhoe B, Moore MV, Tonkin-Crine S, McLeod M, Robotham JV, Walker AS, Wordsworth S. Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study. Antibiotics (Basel) 2020; 9:E608. [PMID: 32947965 PMCID: PMC7558347 DOI: 10.3390/antibiotics9090608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022] Open
Abstract
Delayed antibiotic prescription in primary care has been shown to reduce antibiotic consumption, without increasing risk of complications, yet is not widely used in the UK. We sought to quantify the relative importance of factors affecting the decision to give a delayed prescription, using a stated-choice survey among UK general practitioners. Respondents were asked whether they would provide a delayed or immediate prescription in fifteen hypothetical consultations, described by eight attributes. They were also asked if they would prefer not to prescribe antibiotics. The most important determinants of choice between immediate and delayed prescription were symptoms, duration of illness, and the presence of multiple comorbidities. Respondents were more likely to choose a delayed prescription if the patient preferred not to have antibiotics, but consultation length had little effect. When given the option, respondents chose not to prescribe antibiotics in 51% of cases, with delayed prescription chosen in 21%. Clinical features remained important. Patient preference did not affect the decision to give no antibiotics. We suggest that broader dissemination of the clinical evidence supporting use of delayed prescription for specific presentations may help increase appropriate use. Establishing patient preferences regarding antibiotics may help to overcome concerns about patient acceptance. Increasing consultation length appears unlikely to affect the use of delayed prescription.
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Affiliation(s)
- Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Koen B. Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
| | - Christopher C. Butler
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W2 1PG, UK;
| | - Michael V. Moore
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
| | - Sarah Tonkin-Crine
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Monsey McLeod
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London SW7 2AZ, UK;
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London W2 1NY, UK
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London SW7 2AZ, UK
| | - Julie V. Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London SE1 8UG, UK;
| | - A. Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; (J.B.); (L.S.J.R.); (K.B.P.); (S.W.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.); (A.S.W.)
- NIHR Biomedical Research Centre Oxford, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
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Piñeiro Pérez R, Álvez González F, Baquero-Artigao F, Cruz Cañete M, de la Flor i Bru J, Fernández Landaluce A, García Vera C, Hijano Bandera F, Pérez Cánovas C, Silva Rico JC, Alfayate Miguélez S, Ares Álvarez J, Berghezan Suárez A, Borrull Senra AM, Cabrera Roca G, Calvo Rey C, Carazo Gallego B, Cilleruelo Ortega MJ, Conejo Fernández A, López Ávila J, Lupiani Castellanos P, Martínez Campos L, Sotoca Fernández J. Actualización del documento de consenso sobre el diagnóstico y tratamiento de la faringoamigdalitis aguda. An Pediatr (Barc) 2020; 93:206.e1-206.e8. [DOI: 10.1016/j.anpedi.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/05/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022] Open
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Diagnosis and treatment of acute tonsillopharyngitis. Consensus document update. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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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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Sykes EA, Wu V, Beyea MM, Simpson MTW, Beyea JA. Pharyngitis: Approach to diagnosis and treatment. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:251-257. [PMID: 32273409 PMCID: PMC7145142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To provide family physicians with an updated approach to diagnosis and treatment of pharyngitis, detailing key symptoms, methods of investigation, and a summary of common causes. SOURCES OF INFORMATION The approach described is based on the authors' clinical practice and peer-reviewed literature from 1989 to 2018. MAIN MESSAGE Sore throat caused by pharyngitis is commonly seen in family medicine clinics and is caused by inflammation of the pharynx and surrounding tissues. Pharyngitis can be caused by viral, bacterial, or fungal infections. Viral causes are often self-limiting, while bacterial and fungal infections typically require antimicrobial therapy. Rapid antigen detection tests and throat cultures can be used with clinical findings to identify the inciting organism. Pharyngitis caused by Streptococcus pyogenes is among the most concerning owing to its associated severe complications such as acute rheumatic fever and glomerulonephritis. Hence, careful diagnosis of pharyngitis is necessary to provide targeted treatment. CONCLUSION A thorough history is key to diagnosing pharyngitis. Rapid antigen detection tests should be reserved for concerns about antibiotic initiation. Physicians should exercise restraint in antibiotic initiation for pharyngitis, as restraint does not delay recovery or increase the risk of S pyogenes infections.
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Affiliation(s)
- Edward A Sykes
- First-year resident, Department of Otolaryngology-Head and Neck Surgery at the University of Toronto in Ontario
| | - Vincent Wu
- Second-year resident, Department of Otolaryngology-Head and Neck Surgery at the University of Toronto in Ontario
| | - Michael M Beyea
- Fifth-year resident in the Department of Emergency Medicine at Western University in London, Ont
| | - Matthew T W Simpson
- Family physician in the Department of Family Medicine at Queen's University in Kingston, Ont
| | - Jason A Beyea
- Assistant Professor and Research Director in the Department of Otolaryngology at Queen's University and Adjunct Scientist with ICES Queen's.
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Sykes EA, Wu V, Beyea MM, Simpson MTW, Beyea JA. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:e119-e126. [PMID: 32273424 PMCID: PMC7145122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Objectif Offrir aux médecins de famille une approche diagnostique et thérapeutique actualisée de la pharyngite, en décrivant en détail les principaux symptômes, les méthodes d’investigation et un résumé des causes courantes. Sources d’information L’approche décrite est basée sur la pratique clinique des auteurs et sur les publications revues par les pairs de 1989 à 2018. Message principal Le mal de gorge causé par la pharyngite est couramment observé dans les cliniques de médecine familiale; il est causé par l’inflammation du pharynx et des tissus environnants. La pharyngite est causée par une infection virale, bactérienne ou fongique. Les causes virales sont souvent spontanément résolutives, alors que les infections bactériennes et fongiques nécessitent habituellement l’antibiothérapie. Le test de détection rapide de l’antigène et la culture de gorge sont jumelés aux observations cliniques pour identifier l’organisme en cause. La pharyngite causée par streptococcus pyogenes fait partie des organismes les plus préoccupants en raison de ses complications graves, telles la fièvre rhumatismale aiguë et la glomérulonéphrite. Ainsi, il est nécessaire de poser un diagnostic attentif de pharyngite afin de pouvoir dispenser un traitement ciblé. Conclusion L’anamnèse détaillée est la clé du diagnostic de pharyngite. Le test de détection rapide de l’antigène doit être réservé aux cas où l’instauration de l’antibiothérapie est préoccupante. Les médecins doivent user de retenue lorsqu’ils instaurent l’antibiothérapie contre la pharyngite, puisque la retenue ne retarde pas le rétablissement ni n’augmente le risque d’infection à s. pyogenes.
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Affiliation(s)
| | - Vincent Wu
- Résident de deuxième année au département d'oto-rhino-laryngologie - Chirurgie de la tête et du cou à l'Université de Toronto, en Ontario
| | - Michael M Beyea
- Résident de cinquième année au département de médecine d'urgence à l'Université Western à London, Ontario
| | - Matthew T W Simpson
- Médecin de famille au département de médecine familiale à l'Université Queen's à Kingston, Ontario
| | - Jason A Beyea
- Professeur adjoint et directeur de la recherche au département d'oto-rhino-laryngologie de l'Université Queen's, et scientifique agrégé à l'ICES de l'Université Queen's.
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Mantzourani E, Evans A, Cannings-John R, Ahmed H, Hood K, Reid N, Howe R, Williams E, Way C. Impact of a pilot NHS-funded sore throat test and treat service in community pharmacies on provision and quality of patient care. BMJ Open Qual 2020; 9:e000833. [PMID: 32111608 PMCID: PMC7047494 DOI: 10.1136/bmjoq-2019-000833] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/08/2020] [Accepted: 02/11/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE A National Health Service (NHS)-funded sore throat test and treat (STTT) service was introduced in selected pharmacies in two local health boards in Wales, as an extension to the national pharmacy common ailment scheme. The aim of this study was to evaluate the impact of STTT on provision and quality of patient care, namely antibiotic use, patient safety and general practitioner (GP) consultation rates. METHODS Secondary analyses of STTT consultation data to describe service outcomes, and routine data to explore changes in antibiotic prescribing and the prevalence of complications. Data were also collected from one GP practice to explore the feasibility of measuring changes in sore throat consultation rates in general practice. RESULTS Less than 20% of 1725 consultations resulted in antibiotic supply. The availability of STTT was associated with greater reductions in prescriptions for phenoxymethylpenicillin than in areas where STTT was not available (-3.8% and -3.4%, difference 0.4%). When pharmacy supplies were included, the reductions in the supply of the antibiotic were similar. No increase in the monthly number of incidents of quinsy was detected, and patients were appropriately referred to other healthcare professionals during pharmacy consultations. GP consultation rates since introduction of STTT were found to be lower than the equivalent monthly average since 2014. CONCLUSIONS Data from the first 5 months of the STTT service suggest that it may have a role in safely rebalancing uncomplicated sore throat management from general practice to community pharmacies while continuing to promote antibiotic stewardship.
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Affiliation(s)
- Efi Mantzourani
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
- Primary Care, Information and Communications Technology, NHS Wales Informatics Service, Cardiff, UK
| | - Andrew Evans
- Health and Social Services Group, Welsh Government, Cardiff, UK
| | | | - Haroon Ahmed
- Division of Population Medicine, Cardiff University, Cardiff, South Glamorgan, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, South Glamorgan, UK
| | - Nicholas Reid
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
- Health Protection Division, Public Health Wales, Cardiff, UK
| | - Robin Howe
- Microbiology, Public Health Wales, Cardiff, UK
| | - Emma Williams
- Primary Care, Information and Communications Technology, NHS Wales Informatics Service, Cardiff, UK
| | - Cheryl Way
- Clinical Informatics, NHS Wales Informatics Service, Cardiff, UK
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Implementation of a Highly Accurate Rapid Point-of-Care Test for Group a Streptococcus Detection at a Large Pediatric Emergency Department in South London. Pediatr Infect Dis J 2019; 38:e183-e185. [PMID: 31310596 DOI: 10.1097/inf.0000000000002284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Rapid group A Streptococcus point-of-care testing is not currently used in the United Kingdom in the management of acute tonsillitis. This prospective, observational study describes a strong association between a molecular-based point-of-care testing result and outpatient antibiotic prescribing (odds ratio = 48; P < 0.001) in 339 children seen at our center. It highlights challenges in implementing new rapid diagnostics.
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Frost HM, Fritsche TR, Hall MC. Beta-Hemolytic Nongroup A Streptococcal Pharyngitis in Children. J Pediatr 2019; 206:268-273.e1. [PMID: 30528760 DOI: 10.1016/j.jpeds.2018.10.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/09/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the epidemiology, clinical features, and antibiotic prescribing patterns for nongroup A streptococci (NGAS) in children. STUDY DESIGN Throat cultures obtained for pharyngitis were assessed at a large community-based health system over 10 years. Epidemiologic and clinical features of children with NGAS were compared with children with group A Streptococcus (GAS) and negative cultures. Antibiotic prescribing patterns were evaluated. RESULTS A total of 224 328 rapid streptococcal antigen tests and 116 578 throat cultures were performed. Clinical analysis was completed for 602 GAS-positive patients, 535 NGAS-positive patients, and 480 patients with negative cultures. Incidence of NGAS did not vary annually or by season but increased with age from 2% at ≤5 years to 7% at 18 years of age. Patients with NGAS were more likely than those with negative cultures to have tonsillar exudate (20.3% vs 13.1%, P = .003) and enlarged tonsils (28.6% vs 19.3%, P < .001). Modified Centor scores did not differ between groups (score ≥2, P = 1.0; score ≥3, P = .50). Patients with GAS were more likely than those with NGAS to have fever (32.6% vs 24.5%, P = .003), palatal petechiae (14.0% vs 3.1%, P < .001), and modified Centor score ≥2 (47.8% vs 27.1%; P < .001). Of patients with NGAS, 65% were prescribed antibiotics. CONCLUSIONS NGAS likely exist in both carriage and infectious states and incidence increases with age. Infections associated with NGAS are milder than with GAS, and complications are rare. Laboratory reporting of NGAS results in high antibiotic use, despite current recommendations against treatment.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, University of Colorado, Aurora, CO; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO; Marshfield Clinic Research Institute, Marshfield, WI.
| | - Thomas R Fritsche
- Marshfield Clinic Research Institute, Marshfield, WI; Department of Pathology, Marshfield Clinic Health System, Marshfield, WI
| | - Matthew C Hall
- Department of Medicine, Division of Infectious Diseases, Marshfield Clinic Health System, Marshfield, WI
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Wilcox CR, Stuart B, Leaver H, Lown M, Willcox M, Moore M, Little P. Effectiveness of the probiotic Streptococcus salivarius K12 for the treatment and/or prevention of sore throat: a systematic review. Clin Microbiol Infect 2019; 25:673-680. [PMID: 30616011 DOI: 10.1016/j.cmi.2018.12.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/21/2018] [Accepted: 12/23/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Sore throat resulting from pharyngotonsillitis is one of the commonest reasons for primary care consultation and inappropriate antibiotic prescription and finding effective alternative treatments is important. OBJECTIVES To review the evidence for using the probiotic Streptococcus salivarius K12 (SsK12) for the prevention or treatment of pharyngotonsillitis. DATA SOURCES PubMed, Embase, CINAHL and Cochrane Library. STUDY ELIGIBILITY CRITERIA Randomized controlled trials (RCTs). PARTICIPANTS Adults or children. INTERVENTIONS SsK12 as active treatment or prophylaxis, against pharyngotonsillitis. METHODS Literature search. RESULTS Four articles were identified (1846 participants). All were deemed to be of poor quality using the Cochrane risk-of-bias assessment. Two trials studied SsK12 prophylaxis for streptococcal pharyngitis (children without history of recurrence). One compared daily administration of SsK12 to no treatment over 6 months (n = 222, age 33-45 months), reporting significantly lower incidence in the SsK12 group (16.2% vs. 48.6%, p < 0.01), whereas another placebo-controlled RCT over four school terms (n = 1314, 5-14 years) found no significant difference (7.8% vs. 8.8%, p 0.34) with SsK12 (administered on school days). Another trial found daily SsK12 to significantly protect children (n = 250, 6-7 years) against chronic adenoiditis exacerbation over 3 months compared to no treatment (71.7% vs. 100%, p < 0.0001). The one placebo-controlled RCT in adults that studied the use of SsK12 for acute pharyngotonsillitis (concurrently with penicillin) showed no significant benefit. In all trials, SsK12 was safe and well tolerated. CONCLUSIONS SsK12 appears safe and well tolerated. However, further RCTs are required to establish its role as a prophylactic therapy, particularly among patients experiencing frequent exacerbations of pharyngitis. In the acute setting, SsK12 is unlikely to be effective if given concurrently with antibiotics; however, further RCTs should establish its role as an alternative to antibiotics in nonsevere cases or when prescribed after antibiotic therapy for the prevention of disease recurrence and/or secondary infection.
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Affiliation(s)
- C R Wilcox
- NIHR Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, UK; Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK.
| | - B Stuart
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - H Leaver
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - M Lown
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - M Willcox
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - M Moore
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - P Little
- Department of Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
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Little P, Hobbs FDR, Moore M, Mant D, Williamson I, McNulty C, Lasseter G, Cheng MYE, Leydon G, McDermott L, Turner D, Pinedo-Villanueva R, Raftery J, Glasziou P, Mullee M. Corrigendum: PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess 2018. [DOI: 10.3310/hta18060-c201810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract
The text in Chapter 4, Results, Main findings, Complications has been replaced with the following text [these data do not alter the economic modelling (which was based on the correct data), nor the inferences from the trial that the FeverPAIN score is the optimal management approach]:
There were very few complications in any trial groups: during the first trial phase there were two cases of otitis media and one case of cellulitis in the clinical score group and one case of cellulitis in the delayed antibiotic group; during the second trial phase (when using the FeverPAIN score) there were two cases of quinsy in the delayed antibiotic group and one case of otitis media in the RADT group.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - FD Richard Hobbs
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Mant
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian Williamson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Cliodna McNulty
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - Gemma Lasseter
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - MY Edith Cheng
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Lisa McDermott
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Turner
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | | | - James Raftery
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Paul Glasziou
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
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Little P, Stuart B, Wingrove Z, Mullee M, Thomas T, Johnson S, Leydon G, Richards-Hall S, Williamson I, Yao L, Zhu S, Moore M. Probiotic capsules and xylitol chewing gum to manage symptoms of pharyngitis: a randomized controlled factorial trial. CMAJ 2017; 189:E1543-E1550. [PMID: 29255098 DOI: 10.1503/cmaj.170599] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Reducing the use of antibiotics for upper respiratory tract infections is needed to limit the global threat of antibiotic resistance. We estimated the effectiveness of probiotics and xylitol for the management of pharyngitis. METHODS In this parallel-group factorial randomized controlled trial, participants in primary care (aged 3 years or older) with pharyngitis underwent randomization by nurses who provided sequential intervention packs. Pack contents for 3 kinds of material and advice were previously determined by computer-generated random numbers: no chewing gum, xylitol-based chewing gum (15% xylitol; 5 pieces daily) and sorbitol gum (5 pieces daily). Half of each group were also randomly assigned to receive either probiotic capsules (containing 24 × 109 colony-forming units of lactobacilli and bifidobacteria) or placebo. The primary outcome was mean self-reported severity of sore throat and difficulty swallowing (scale 0-6) in the first 3 days. We used multiple imputation to avoid the assumption that data were missing completely at random. RESULTS A total of 1009 individuals consented, 934 completed the baseline assessment, and 689 provided complete data for the primary outcome. Probiotics were not effective in reducing the severity of symptoms: mean severity scores 2.75 with no probiotic and 2.78 with probiotic (adjusted difference -0.001, 95% confidence interval [CI] -0.24 to 0.24). Chewing gum was also ineffective: mean severity scores 2.73 without gum, 2.72 with sorbitol gum (adjusted difference 0.07, 95% CI -0.23 to 0.37) and 2.73 with xylitol gum (adjusted difference 0.01, 95% CI -0.29 to 0.30). None of the secondary outcomes differed significantly between groups, and no harms were reported. INTERPRETATION Neither probiotics nor advice to chew xylitol-based chewing gum was effective for managing pharyngitis. Trial registration: ISRCTN, no. ISRCTN51472596.
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Affiliation(s)
- Paul Little
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Beth Stuart
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Zoe Wingrove
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Mark Mullee
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Tammy Thomas
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Sophie Johnson
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Gerry Leydon
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Samantha Richards-Hall
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Ian Williamson
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Lily Yao
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Shihua Zhu
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Michael Moore
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
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Moore M, Stuart B, Hobbs FR, Butler CC, Hay AD, Campbell J, Delaney BC, Broomfield S, Barratt P, Hood K, Everitt HA, Mullee M, Williamson I, Mant D, Little P. Symptom response to antibiotic prescribing strategies in acute sore throat in adults: the DESCARTE prospective cohort study in UK general practice. Br J Gen Pract 2017; 67:e634-e642. [PMID: 28808075 PMCID: PMC5569743 DOI: 10.3399/bjgp17x692321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/15/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND A delayed or 'just in case' prescription has been identified as having potential to reduce antibiotic use in sore throat. AIM To determine the symptomatic outcome of acute sore throat in adults according to antibiotic prescription strategy in routine care. DESIGN AND SETTING A secondary analysis of the DESCARTE (Decision rule for the Symptoms and Complications of Acute Red Throat in Everyday practice) prospective cohort study comprising adults aged ≥16 years presenting with acute sore throat (≤2 weeks' duration) managed with treatment as usual in primary care in the UK. METHOD A random sample of 2876 people from the full cohort were requested to complete a symptom diary. A brief clinical proforma was used to collect symptom severity and examination findings at presentation. Outcome details were collected by notes review and a detailed symptom diary. The primary outcome was poorer 'global' symptom control (defined as longer than the median duration or higher than median symptom severity). Analyses controlled for confounding by indication (propensity to prescribe antibiotics). RESULTS A total of 1629/2876 (57%) of those requested returned a symptom diary, of whom 1512 had information on prescribing strategy. The proportion with poorer global symptom control was greater in those not prescribed antibiotics 398/587 (68%) compared with those prescribed immediate antibiotics 441/728 (61%) or delayed antibiotic prescription 116/197 59%); adjusted risk ratio (RR) (95% confidence intervals [CI]): immediate RR 0.87 (95% CI = 0.70 to 0.96), P = 0.006; delayed RR 0.88 (95% CI = 0.78 to 1.00), P = 0.042. CONCLUSION In the routine care of adults with sore throat, a delayed antibiotic strategy confers similar symptomatic benefits to immediate antibiotics compared with no antibiotics. If a decision is made to prescribe an antibiotic, a delayed antibiotic strategy is likely to yield similar symptomatic benefit to immediate antibiotics.
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Affiliation(s)
- Michael Moore
- Primary Care and Population Sciences Division, University of Southampton
| | - Beth Stuart
- Primary Care and Population Sciences Division, University of Southampton
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol
| | | | - Brendan C Delaney
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London
| | - Sue Broomfield
- Primary Care and Population Sciences Division, University of Southampton
| | - Paula Barratt
- Primary Care and Population Sciences Division, University of Southampton
| | - Kerenza Hood
- Centre for trials research, South East Wales Trials Unit, Institute of Primary Care and Public Health, School of Medicine, Cardiff University
| | - Hazel A Everitt
- Primary Care and Population Sciences Division, University of Southampton
| | - Mark Mullee
- Primary Care and Population Sciences Division, University of Southampton
| | - Ian Williamson
- Primary Care and Population Sciences Division, University of Southampton
| | - David Mant
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton
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Influence of the duration of penicillin prescriptions on outcomes for acute sore throat in adults: the DESCARTE prospective cohort study in UK general practice. Br J Gen Pract 2017; 67:e623-e633. [PMID: 28808076 DOI: 10.3399/bjgp17x692333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/15/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Guidelines recommend 10-day treatment courses for acute sore throat, but shorter courses may be used in practice. AIM To determine whether antibiotic duration predicts adverse outcome of acute sore throat in adults in routine care. DESIGN AND SETTING A secondary analysis of the DESCARTE (Decision rule for the Symptoms and Complications of Acute Red Throat in Everyday practice) prospective cohort study of 12 829 adults presenting in UK general practice with acute sore throat. METHOD A brief clinical proforma was used to collect symptom severity and examination findings at presentation. Outcomes were collected by notes review, a sample also completed a symptom diary. The primary outcome was re-consultation with new/non-resolving symptoms within 1 month. The secondary outcome was 'global' poorer symptom control (longer than the median duration or higher than median severity). RESULTS Antibiotics were prescribed for 62% (7872/12 677) of participants. The most commonly prescribed antibiotic was phenoxymethylpenicillin (76%, 5656/7474) and prescription durations were largely for 5 (20%), 7 (57%), or 10 (22%) days. Compared with 5-day courses, those receiving longer courses were less likely to re-consult with new or non-resolving symptoms (5 days 15.3%, 7 days 13.9%, 10 days 12.2%, 7-day course adjusted risk ratio (RR) 0.92 [95% confidence interval [CI] = 0.76 to 1.11] and 10-days RR 0.86 [95% CI = 0.59 to 1.23]) but these differences did not reach statistical significance. CONCLUSION In adults prescribed antibiotics for sore throat, the authors cannot rule out a small advantage in terms of reduced re-consultation for a 10-day course of penicillin, but the effect is likely to be small.
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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. Hippokratia 2016. [DOI: 10.1002/14651858.cd012431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Jérémie F Cohen
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes University; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé); Paris France
| | - Jean-Yves Pauchard
- Hôpital de lEnfance de Lausanne, Centre Hospitalier Universitaire Vaudois; Département Médico-Chirurgical de Pédiatrie; Rue du Bugnon 46 Lausanne Switzerland CH-1011
| | - Nils Hjelm
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes University; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé); Paris France
| | - Robert Cohen
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV); 27 Rue Inkermann Saint-Maur-des-Fossés France
| | - Martin Chalumeau
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS), Inserm UMR1153, Paris Descartes University; Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé); Paris France
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Thornley T, Marshall G, Howard P, Wilson APR. A feasibility service evaluation of screening and treatment of group A streptococcal pharyngitis in community pharmacies. J Antimicrob Chemother 2016; 71:3293-3299. [PMID: 27439523 PMCID: PMC5079295 DOI: 10.1093/jac/dkw264] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 05/24/2016] [Accepted: 05/30/2016] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES The UK 5 year antimicrobial resistance strategy recognizes the role of point-of-care diagnostics to identify where antimicrobials are required, as well as to assess the appropriateness of the diagnosis and treatment. A sore throat test-and-treat service was introduced in 35 community pharmacies across two localities in England during 2014-15. METHODS Trained pharmacy staff assessed patients presenting with a sore throat using the Centor scoring system and patients meeting three or all four of the criteria were offered a throat swab test for Streptococcus pyogenes, Lancefield group A streptococci. Patients with a positive throat swab test were offered antibiotic treatment. RESULTS Following screening by pharmacy staff, 149/367 (40.6%) patients were eligible for throat swab testing. Of these, only 36/149 (24.2%) were positive for group A streptococci. Antibiotics were supplied to 9.8% (n = 36/367) of all patients accessing the service. Just under half of patients that were not showing signs of a bacterial infection (60/123, 48.8%) would have gone to their general practitioner if the service had not been available. CONCLUSIONS This study has shown that it is feasible to deliver a community-pharmacy-based screening and treatment service using point-of-care testing. This type of service has the potential to support the antimicrobial resistance agenda by reducing unnecessary antibiotic use and inappropriate antibiotic consumption.
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Affiliation(s)
- T Thornley
- Boots UK, Nottingham NG90 1BS, UK
- School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
| | | | - P Howard
- Medicines Management & Pharmacy, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
| | - A P R Wilson
- Department of Microbiology & Virology, University College London Hospitals, London W1T 4EU, UK
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Kanji K, Saatci D, Rao GG, Khanna P, Bassett P, Williams B, Khan M. Antibiotics for tonsillitis: should the emergency department emulate general practice? J Clin Pathol 2016; 69:834-6. [DOI: 10.1136/jclinpath-2016-203808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 06/08/2016] [Indexed: 11/04/2022]
Abstract
ObjectivesTo determine whether antibiotics are prescribed appropriately for acute tonsillitis in an emergency department (ED).MethodsCross-sectional observational study in large district general hospital in London. Patients diagnosed and coded with ‘acute tonsillitis’ in the ED over a 3-month period in 2015. Medical records were reviewed for Centor criteria, which is a clinical scoring system to guide antibiotic prescribing in UK general practice. Drug charts were reviewed for the specific antibiotic(s) prescribed, and throat swab (TS) cultures were recorded.Results273/389 patients with tonsillitis were analysed—186 children, 87 adults. Exclusions were missing patient records (86), patients had/awaiting tonsillectomy (22), receiving antibiotics (6) and immunocompromised (2). Centor score (CS) was not recorded for any patient. Based on derived CS from documented signs/symptoms, antibiotics were prescribed inappropriately to 196/273 patients (80%; 95% CI 74% to 85%) including broad-spectrum antibiotics to 25%. These included co-amoxiclav (18%), amoxicillin (6%), azithromycin (0.5%) and ceftriaxone (0.5%). TSs were taken in 66/273(24%) patients; 10/66 were positive for group A streptococcus (GAS). However, 48/56 GAS negative patients were prescribed antibiotics.ConclusionsCS was not being used in the ED to guide antibiotic prescribing for acute tonsillitis. Antibiotic prescribing was based on clinical judgement. Based on derived CS (<3), 80% of patients were inappropriately prescribed antibiotics, particularly broad-spectrum antibiotics. Further studies need to assess use of CS to guide antibiotic prescription in ED. TSs were commonly performed in the ED but did not either improve diagnosis or guide antibiotic prescription.
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Windfuhr JP, Toepfner N, Steffen G, Waldfahrer F, Berner R. Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management. Eur Arch Otorhinolaryngol 2016; 273:973-87. [PMID: 26755048 PMCID: PMC7087627 DOI: 10.1007/s00405-015-3872-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/17/2015] [Indexed: 12/14/2022]
Abstract
More than 120,000 patients are treated annually in Germany to resolve repeated episodes of acute tonsillitis. Therapy is aiming at symptom regression, avoidance of complications, reduction in the number of disease-related absences in school or at work, increased cost-effectiveness and improved quality of life. The purpose of this part of the guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through different conservative treatment options in order to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical management in terms of intracapsular as well as extracapsular tonsillectomy (i.e. tonsillotomy) is the subject of part II of this guideline. To estimate the probability of tonsillitis caused by β-hemolytic streptococci, a diagnostic scoring system according to Centor or McIsaac is suggested. If therapy is considered, a positive score of ≥3 should lead to pharyngeal swab or rapid test or culture in order to identify β-hemolytic streptococci. Routinely performed blood tests for acute tonsillitis are not indicated. After acute streptococcal tonsillitis, there is no need to repeat a pharyngeal swab or any other routine blood tests, urine examinations or cardiological diagnostics such as ECG. The determination of the antistreptolysin O-titer (ASLO titer) and other antistreptococcal antibody titers do not have any value in relation to acute tonsillitis with or without pharyngitis and should not be performed. First-line therapy of β-hemolytic streptococci consists of oral penicillin. Instead of phenoxymethylpenicillin–potassium (penicillin V potassium), also phenoxymethlpenicillin–benzathine with a clearly longer half-life can be used. Oral intake for 7 days of one of both the drugs is recommended. Alternative treatment with oral cephalosporins (e.g. cefadroxil, cefalexin) is indicated only in cases of penicillin failure, frequent recurrences, and whenever a more reliable eradication of β-hemolytic streptococci is desirable. In cases of allergy or incompatibility of penicillin, cephalosporins or macrolides (e.g. Erythromycin-estolate) are valuable alternatives.
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Affiliation(s)
- Jochen P Windfuhr
- Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf, Sandradstr. 43, 41061, Mönchengladbach, Germany.
| | - Nicole Toepfner
- Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | | | - Frank Waldfahrer
- Department of Otolaryngology, Head and Neck Surgery, University Hospital of Erlangen, Waldstr. 1, 91054, Erlangen, Germany
| | - Reinhard Berner
- Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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