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A patient may present with symptoms of viral and bacterial infection. Antibiotics are appropriate for those with bacterial pharyngitis.

•Viral infection

•Group A Strep (GAS)

•Infectious mononucleosis

•Mycoplasma

•Chlamydia

•Influenza

•Diphtheria

•Necrotizing gingivostomatitis

•Abscess

•Epiglottitis

•Acute HIV infection

•Xerostomia

•Carcinoma

Testing and treatment of asymptomatic family members is not advocated.

Scope and Practice

Objective: to provide recommendations on the management of GAS pharyngitis among adult and pediatric patients; discuss diagnosis and management and provide recommendations regarding choice of antibiotic and dosing.

The guideline addresses diagnosis and management of GAS

This guideline applies to adults and pediatrics seen in family practice, infectious disease, and internal medicine practices.

(Shulman et al., 2012)

Stakeholders

  • Consensus was developed from a panel of multi-disciplinary experts including clinicians from infectious disease, internists, and pediatricians.

  • This was sponsored by the Infectious Disease Society of America which is a non-profit professional association.

  • This guideline was meant to be used by Advanced Practice Nurses, Physician Assistants, Physicians and Nurses.

  • Feedback was obtained from external peer reviews while drafting the guideline.

(Shulman et al., 2012)

Evidence-Based Methodology

  • Hand and electric searches where conducted of primary and secondary sources. Articles that were included dated 1980-2012. Only 7 key terms were used to search for articles.

  • Evidence tables are available. The GRADE approach was used to determine quality of evidence used.

  • The strongest evidence was compiled into “Major Recommendations”.

  • Teleconferences were held to communicate and form consensus.

  • Potential harms and benefits of using the guideline were listed.

  • The Guideline was written in 1997 and recently updated in 2012. The guideline is reviewed annually.

(Shulman et. al., 2012)

Antimicrobial prescribing in the USA for adult acute pharyngitis in relation to treatment guidelines.

Diagnosis and Management of Pharyngitis

Using a Clinical Practice Guideline to Deliver Excellent Primary Care

Case Study

Research

A 24 year old female presents to the office reporting a sore throat for 4 days. She complains of nasal congestion, hoarseness, and a cough. She states "I need an antibiotic, I am going to lose my job if I don't get back to work soon."

Her BP is 112/68, HR 72, Temp 99.3(o), R 18 and she rates the pain in her throat a 4/10. No tonsillar exudates, and lymph nodes non-palpable.

Problem:

  • Historically, primary care providers have prescribed broad spectrum antibiotics to treat all cases of pharyngitis.

  • This has led to resistance.

  • Reasons why this practice has continued include patient expectations, limited time, and concern about follow-up.

  • Only five to seventeen percent of adult cases of acute pharyngitis are GAS.

Aim:

(Hong, Taur, Jordan, & Wanke, 2011)

To analyze primary care providers prescribing practices in the United States for acute pharyngitis and to evaluate how often clinicians are following the guideline developed by the American College of Physicians (ACP) in 2001.

(Hong, et al., 2011)

Purpose:

To determine if antibiotic prescribing is reduced when following a clinical guideline. Also, to assist in providing a way for physicians to prescribe antibiotics more judiciously to prevent antimicrobial resistance in the general population.

  • 11.9% of visits were diagnosed with GAS pharyngitis.

  • 62.6% of patients were prescribed antibiotics.

  • There was a slight decrease from 66.5% to 59.1% after the ACP introduced their guidelines.

  • Women and the elderly were less likely to receive a prescription for antibiotics.

  • Patients that had private insurance were more likely to receive a prescription for antibiotics.

(Hong, et al., 2011)

(Hong et al., 2011)

Research Problem,

Aim and Purpose

Research

Method and Design

Results

How would you treat her and what education would you provide?

Discussion

References

Buttaravoli, P., & Leffler, S. M. (2012). Minor emergencies (3rd. ed.). Philadelphia, PA: Elsevier Saunders.

Hong, S. Y., Taur, Y., Jordan, M. R., & Wanke, C. (2011). Antimicrobial prescribing in the USA for adult acute pharyngitis in relation to treatment guidelines. Journal Of Evaluation In Clinical Practice, 17(6), 1176-1183. doi:10.1111/j.1365-2753.2010.01495

Shulman, S. T., Bisno, A. L., Clegg, H. W., Gerber, M. A., Kaplan, E. L., Lee, G., & Van Beneden, C. (2012).

Clinical practice guideline for the diagnosis and management of group a streptococcal pharyngitis: 2012 update by the infectious diseases society of America. Clinical Infectious Diseases, 55(10), 1279-1282. doi: 10.1093/cid/cis629

Skyscape Clinical Constellation: All-in-One Clinical Solution. (2010). Retrieved from www.skyscape.com/ustf

  • This is the first study to identify that prescribing habits are affected by clinical guideline release.

  • Campaign and education efforts have been effective at reducing unnecessary antibiotic prescription, but more awareness is needed.

  • Obstacles include: Agreement on one guideline, providers are unable to perform the recommendations, or the belief that simply following the guidelines will not improve patient outcomes. Patient demand also plays into this dynamic.
  • Researchers performed analysis of 3791 office visits for acute pharyngitis between 1996-2006. They used two separate databases gathered at the National Center for Health Statistics.

  • All cases were identified by ICD-9 coding.

  • Information was gathered using a multilevel sample design.

  • Researchers looked at whether a strep test was performed and, if any, which antibiotics were prescribed.

  • Information was compared to determine if there was a change in practice after the ACP guideline was published.

(Hong, et al., 2011)

Diagnostic Recommendations

Treatment Guidelines

(Hong, et al., 2011)

(Shulman et al., 2012)

1. Perform a throat swab with a rapid antigen detection test (RADT) and/or a throat culture to differentiate viral vs. bacterial infection if symptoms do not clearly indicate a viral infection. Cost of the test kit is less than $2.

2. Positive RADTs are highly specific and do not need to be followed with a back-up throat culture.

3. With most adults the risk of rheumatic fever is low, so it is not recommended to do a throat culture following a negative RADT. However the provider may choose to perform a conventional throat culture on an individual patient basis.

4. Anti-streptococcal antibody titers are no longer recommended.

1. Patients with acute GAS pharyngitis should be treated with an antibiotic.

2. For adults without a penicillin allergy the antibiotic of choice is is Penicillin because it has a narrow spectrum of activity, few side effects, and is affordable. The generic form is available for free at some pharmacies.

Common prescription would be:

Penicillin 250 mg PO four times daily, or 500 mg PO twice daily for 10 days.

3. For adults with a penicillin allergy cephalexin is the antibiotic of choice. This medication is available for $20-40.

Common prescription would be:

Cephalexin 20 mg/kg/dose PO twice daily (max = 500 mg/dose) for 10 days.

4. Adults with chronic GAS are often only carriers and are not contiguous, therefore antibiotic therapy is not indicated.

5. Tonsillectomy is no longer recommended for chronic GAS.

(Shulman et al., 2012)

Adjunct Treatment Guidelines for GAS

(Shulman et al., 2012)

1. Use NSAIDS or Tylenol to alleviate symptoms such as pain and fever.

2. The use of corticosteroids is not supported by research.

(Shulman et al., 2012)

Editorial Independence

Implementation

Ease of Use and Clarity

The guideline did not include an implementation strategy or patient resources.

(Shulman et al., 2012)

Recommendations are easily identified, specific, and understandable. (Shulman et al., 2012)

The guideline committee members were required to disclose all potential conflicts of interest. The editors included all those relevant to the content. (Shulman et al., 2012)

What could cause a sore throat?

Diagnosis and

Treatment

Recommendations

Application of the guideline

Evaluation of the guideline

Strengths and

Weaknesses

of the Guideline

Differential Diagnosis

Strengths

Weaknesses

  • Able to use in a wide variety of settings and patient centered.

  • Created by an Unbiased panel of experts.

  • Uses a strength of recommendations grading system.

  • Conflicts of interest are identified and addressed.
  • No implementation tools created.

  • No cost analysis provided.

The National Guideline Clearinghouse was used to compare several guidelines.

This guideline is the most up-to-date and easy to follow. It also applies to most patient populations and can be used in a wide variety of clinical settings.

The use of this guideline by providers, such as APNs, will help reduce microbial resistance.

Summary and Evaluation of the Clinical Guideline

Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America (IDSA).

The Centor scoring system is used for adults and categorizes people into high and low risk. High risk people have three or four of the following symptoms:

Tonsillar Exudates

Tender anterior cevical lymphadenopathy

Absence of a cough

History of fever

The McIsaac system is used for children and adults. High risk patients met 4 or 5 of the following criteria:

Fever

Absence of cough

Tender anterior cevical lymphadenopathy

Tonsillar Exudates or swelling

Age of 15 or younger

High risk patients should be treated with antibiotics.

Moderate risk should be tested for GAS before treatment.

Children should always be tested because of the risk of rheumatic fever.

(Buttaravoli & Leffler, 2012)

What is Pharyngitis?

(skyscape, 2010)

It is an infection of the pharynx which causes a sore throat. There are two types:

Bacterial

Viral

  • Rapid onset with painful swallowing
  • Fever
  • Pharyngeal erythema
  • Edematous uvula
  • Palatine petechiae
  • Purulent, yellow patchy, gray or white exudate
  • Tender anterior cervical andenopathy
  • Headache
  • Absence of cough
  • N/V and abdominal pain
  • Scalartiniform Rash
  • Winter and early spring presentation

  • Often appears with conjunctivitis
  • Nasal congestion
  • Hoarseness
  • Cough
  • Aphthous ulcers on the soft palate
  • Myalgias
  • Diarrhea
  • Discrete ulcerative stomatitis
  • Viral exanthema

(Buttaravoli & Leffler, 2012)

(Shulman, Bisno, Clegg, Gerber, Kaplan, Lee, & Van Beneden, 2012)

(Buttaravoli & Leffler, 2012)

(Shulman et al., 2012)

Ashley Boettcher & Sarah Weaver

Saint Francis University: Nursing 570

January, 2013

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