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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.
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)
(Shulman et al., 2012)
(Shulman et. al., 2012)
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.
(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)
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.
(Hong, et al., 2011)
(Hong et al., 2011)
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
(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)
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)
Differential Diagnosis
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.
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)
(skyscape, 2010)
Bacterial
Viral
(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