Study shows new approach to managing sore throats
http://www.100md.com
《英国医生杂志》
By following current guidelines for the selective use of throat cultures and antibiotic treatment on the basis of positive rapid test or throat culture results only, doctors can reduce unnecessary use of antibiotics for pharyngitis, a recent study has shown.
Current guidelines for managing pharyngitis vary in their recommendations on antibiotic treatment and the need for laboratory confirmation of group A streptococcus. An estimated 6.7 million visits to a doctor are made by adults with a sore throat in the United States annually. Between 1989 and 1999, 70% of adults presenting with sore throat received an antibiotic prescription.
Dr Warren McIsaac of Mount Sinai Hospital, Toronto, Ontario, and colleagues conducted a study to assess the impact of different clinical guidelines on the appropriateness of antibiotics prescribed, the proportion of cases of sore throat in which group A streptococcus is identified, and the use of throat cultures and rapid tests to detect such cases in a population of children and adults whose chief complaint is a sore throat (JAMA 2004;291:1587-95).
The study obtained throat cultures and rapid antigen tests from 787 children and adults aged 3 to 69 years with acute sore throat attending a family medicine clinic in Calgary, Alberta, from September 1999 to August 2002.
Recent guidelines from the Infectious Diseases Society of America reiterate two principles of management in cases of sore throat: clinical and epidemiological features should be used to distinguish patients who may have group A streptococcus pharyngitis and therefore who should be treated; and antibacterial treatment should be used only for cases confirmed with a laboratory test.
Another set of guidelines—from the American College of Physicians-American Society of Internal Medicine, the American Academy of Family Physicians and the US Centers for Disease Control and Prevention, endorses the Infectious Diseases Society of America抯 approach in children. However, the guidelines recommend a departure from the principle of laboratory confirmation of all adult cases. They recommend the use of a clinical prediction tool, the Centor score, to determine who to test and who to treat directly with no further testing.
The Centor score assigns 1 point each for a temperature greater than 38篊; absence of cough; swollen, tender anterior cervical nodes; tonsillar swelling or exudates; and age between 3 and 14 years. A score of 3 denotes a 25% to 28% risk of streptococcal infection.
The current study compared the approaches recommended by these two sets of guidelines with rapid testing alone, the Centor clinical prediction rule alone, and a standard of treatment for positive throat culture results only.
The researchers found that the selective use of throat cultures as advocated in both sets of guidelines for the management of pharyngitis is compatible with a goal of reducing overall and unnecessary use of antibiotics for treatment of pharyngitis.
Total prescribing of antibiotics was lowest with rapid testing (24.7%; 95% confidence interval 21.7%-27.8%) and highest with empirical treatment of high risk adults (45.7%; 42.4% to 49.3%) due to a high rate of unnecessary prescriptions in adults subsequently shown not to have group A streptococcus. Moreover, empirical antibiotic treatment of adults with a Centor score of 3 or greater as proposed in the American Society of Internal Medicine guidelines may result in 40% of adults being prescribed antibiotics unnecessarily.(New York Scott Gottlieb)
Current guidelines for managing pharyngitis vary in their recommendations on antibiotic treatment and the need for laboratory confirmation of group A streptococcus. An estimated 6.7 million visits to a doctor are made by adults with a sore throat in the United States annually. Between 1989 and 1999, 70% of adults presenting with sore throat received an antibiotic prescription.
Dr Warren McIsaac of Mount Sinai Hospital, Toronto, Ontario, and colleagues conducted a study to assess the impact of different clinical guidelines on the appropriateness of antibiotics prescribed, the proportion of cases of sore throat in which group A streptococcus is identified, and the use of throat cultures and rapid tests to detect such cases in a population of children and adults whose chief complaint is a sore throat (JAMA 2004;291:1587-95).
The study obtained throat cultures and rapid antigen tests from 787 children and adults aged 3 to 69 years with acute sore throat attending a family medicine clinic in Calgary, Alberta, from September 1999 to August 2002.
Recent guidelines from the Infectious Diseases Society of America reiterate two principles of management in cases of sore throat: clinical and epidemiological features should be used to distinguish patients who may have group A streptococcus pharyngitis and therefore who should be treated; and antibacterial treatment should be used only for cases confirmed with a laboratory test.
Another set of guidelines—from the American College of Physicians-American Society of Internal Medicine, the American Academy of Family Physicians and the US Centers for Disease Control and Prevention, endorses the Infectious Diseases Society of America抯 approach in children. However, the guidelines recommend a departure from the principle of laboratory confirmation of all adult cases. They recommend the use of a clinical prediction tool, the Centor score, to determine who to test and who to treat directly with no further testing.
The Centor score assigns 1 point each for a temperature greater than 38篊; absence of cough; swollen, tender anterior cervical nodes; tonsillar swelling or exudates; and age between 3 and 14 years. A score of 3 denotes a 25% to 28% risk of streptococcal infection.
The current study compared the approaches recommended by these two sets of guidelines with rapid testing alone, the Centor clinical prediction rule alone, and a standard of treatment for positive throat culture results only.
The researchers found that the selective use of throat cultures as advocated in both sets of guidelines for the management of pharyngitis is compatible with a goal of reducing overall and unnecessary use of antibiotics for treatment of pharyngitis.
Total prescribing of antibiotics was lowest with rapid testing (24.7%; 95% confidence interval 21.7%-27.8%) and highest with empirical treatment of high risk adults (45.7%; 42.4% to 49.3%) due to a high rate of unnecessary prescriptions in adults subsequently shown not to have group A streptococcus. Moreover, empirical antibiotic treatment of adults with a Centor score of 3 or greater as proposed in the American Society of Internal Medicine guidelines may result in 40% of adults being prescribed antibiotics unnecessarily.(New York Scott Gottlieb)