Elsevier

Clinical Therapeutics

Volume 33, Issue 1, January 2011, Pages 48-58
Clinical Therapeutics

Pediatric, adolescent, & maternal therapeutics
Original research
Analysis of Different Recommendations From International Guidelines for the Management of Acute Pharyngitis in Adults and Children

https://doi.org/10.1016/j.clinthera.2011.02.001Get rights and content

Abstract

Background

Streptococcal pharyngitis is a frequently observed condition, but its optimal management continues to be debated.

Objective

The goal of this study was to evaluate the available guidelines, developed at the national level, for the management of streptococcal pharyngitis in Western countries, with a focus on their differences.

Methods

A literature search was conducted of the Cochrane Library, EMBASE, TRIP, and MEDLINE databases from their inception (1993 for the Cochrane Library, 1980 for EMBASE, 1997 for TRIP, and 1966 for MEDLINE) through April 25, 2010. The following search terms were used: pharyngitis, sore throat, tonsillitis, pharyngotonsillitis, Streptococcus pyogenes, Group A β-haemolytic Streptococcus pyogenes, and streptococcal pharyngitis. Searches were limited to type of article or document (practice guideline or guideline) with no language restrictions or language limits.

Results

Twelve national guidelines were identified: 6 from European countries (France, United Kingdom, Finland, Holland, Scotland, and Belgium), 5 from the United States, and 1 from Canada. Recommendations differ substantially with regard to the use of a rapid antigen diagnostic test or throat culture and the indications for antibiotic treatment. The North American, Finnish, and French guidelines recommend performing one timely microbiologic investigation in suspected cases, and prescribing antibiotics in confirmed cases to prevent suppurative complications and acute rheumatic fever. According to the remaining European guidelines, however, acute sore throat is considered a benign, self-limiting disease. Microbiologic tests are not routinely recommended by these latter guidelines, and antibiotic treatment is reserved for well-selected cases. The use of the Centor score, for evaluation of the risk of streptococcal infection, is recommended by several guidelines, but subsequent decisions on the basis of the results differ in terms of which subjects should undergo microbiologic investigation. All guidelines agree that narrow-spectrum penicillin is the first choice of antibiotic for the treatment of streptococcal pharyngitis and that treatment should last for 10 days to eradicate the microorganism. Once-daily amoxicillin was recommended by 2 US guidelines as equally effective.

Conclusion

The present review found substantial discrepancies in the recommendations for the management of pharyngitis among national guidelines in Europe and North America.

Introduction

Acute pharyngitis is common in adults and children, accounting for ∼5% of medical visits.1 Most cases are viral, benign, and self-limited. Group A β-hemolytic streptococci (GABHS) is the most common bacterial etiology. Among children of all ages who present with sore throat, the prevalence of GABHS has been estimated to be 37% (95% CI, 32–43). Streptococcal pharyngitis occurs at all ages but is most common among school-aged children and adolescents. It is rare in children younger than 3 years. The peak incidence in temperate climates occurs during late autumn, winter, and early spring. The incubation period is 2 to 5 days, and communicability of the infection is highest during the acute phase. Patients are no longer contagious within 24 hours of starting antibiotic treatment.2 Because the signs and symptoms of GABHS pharyngitis overlap extensively with pharyngitis not caused by GABHS, it is not possible to make a diagnosis based solely on clinical findings. No single element of the patient's history or physical examination reliably confirms or excludes GABHS pharyngitis.3 Sore throat, sudden onset of fever (≥38°C), and documented exposure to GABHS within the preceding 2 weeks may suggest streptococcal infection.2 Cervical node adenopathy and pharyngeal or tonsillar inflammation or exudates are common signs, whereas palatal petechiae and scarlatiniform rash are highly specific but uncommon.2 Cough, coryza, conjunctivitis, and diarrhea are more common in viral pharyngitis,4 although toddlers (1–3 years of age) with GABHS pharyngitis initially can have serous rhinitis.2 Suppurative complications include cervical lymphadenitis, peritonsillar abscess, retropharyngeal abscess, otitis media, mastoiditis, and sinusitis occurring in patients in whom the primary illness has gone unnoticed or untreated. Nonsuppurative sequelae are acute rheumatic fever, acute poststreptococcal glomerulonephritis, Sydenham chorea, reactive arthritis, and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.5 Confirmation of GABHS pharyngitis can be performed using a throat culture or rapid antigen diagnostic test (RADT). Several RADTs are available; most are based on nitrous acid extraction of group A carbohydrate antigen from organisms obtained by throat swab. The specificity of these tests is high (89.7%–99%), but the reported sensitivity varies considerably (55%–99%) and is lower with older latex agglutination assays compared with more recent enzyme-linked immunosorbent assays, optical immunoassays, and chemiluminescent DNA probes.2, 6, 7

Several guidelines have been published in North America and Europe. The goal of the present study was to evaluate the available guidelines, which have been developed at the national level, for the management of streptococcal pharyngitis in Western countries, with a focus on their differences.

Section snippets

Materials and Methods

A literature search was conducted of the Cochrane Library, EMBASE, TRIP, and MEDLINE databases from their inception (1993 for the Cochrane Library, 1980 for EMBASE, 1997 for TRIP, and 1966 for MEDLINE) through April 25, 2010. The following search terms were used: pharyngitis, sore throat, tonsillitis, pharyngotonsillitis, Streptococcus pyogenes, Group A β-haemolytic Streptococcus pyogenes, and streptococcal pharyngitis. Searches were limited to type of article or document (practice guideline or

Results

Twelve guidelines were identified: 6 from European countries (France, United Kingdom, Finland, Holland, Scotland, and Belgium), 5 from the United States, and 1 from Canada. Table I2, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 lists the recommendations and their years of publication.

Discussion

In the present review, 12 national guidelines (6 from European countries, 5 from the United States, and 1 from Canada) were analyzed. Recommendations differ substantially with regard to the use of RADT or throat culture and the indications for antibiotic treatment. In general, North American, Finnish, and French guidelines recommend performing one timely microbiologic investigation in suspected cases, and prescribing antibiotics in confirmed cases to prevent suppurative complications and acute

Conclusion

The present review found substantial discrepancies in the recommendations for the management of pharyngitis among national guidelines in Europe and North America.

Acknowledgments

The present research was supported by Tecnimed SRL (Varese, Italy). The authors have indicated that they have no conflicts of interest with regard to the content of this article.

Drs. Chiappini, Regoli, Bonsignori, and Sollai performed the literature search and data interpretation, and wrote the manuscript. Drs. Galli and de Martino performed the data interpretation and final revision of the manuscript.

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