Saturday, March 28, 2009
tonsillitis keelpijn pharingitis
*
Management of Streptococcal Pharyngitis Reviewed CME/CE
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Disclosures
Release Date: March 10, 2009; Valid for credit through March 10, 2010
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians;
Nurses - 0.25 ANCC contact hours (0.25 contact hours are in the area of pharmacology)
To participate in this internet activity: (1) review the target audience, learning objectives, and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation; (4) view/print certificate View details.
Learning Objectives
Upon completion of this activity, participants will be able to:
1. Describe the prevalence, presentation, and diagnosis of group A beta-hemolytic streptococcus pharyngitis.
2. Describe treatment and follow up guidelines for acute, chronic, and recurrent group A beta-hemolytic streptococcus pharyngitis
Authors and Disclosures
Laurie Barclay, MD
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
Désirée Lie, MD, MSEd
Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.
Laurie Scudder, MS, NP
Disclosure: Laurie Scudder, MS, NP, has disclosed no relevant financial information.
Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.
March 10, 2009 — Best practices to diagnose and treat streptococcal pharyngitis in the primary care setting are reviewed in an article published in the March 1 issue of American Family Physician.
"Pharyngitis is diagnosed in 11 million patients in U.S. emergency departments and ambulatory settings annually," writes Beth A. Choby, MD, from University of Tennessee College of Medicine in Chattanooga. "Group A beta-hemolytic streptococcus (GABHS), the most common bacterial etiology, accounts for 15 to 30 percent of cases of acute pharyngitis in children and 5 to 20 percent in adults....The infection is transmitted via respiratory secretions, and the incubation period is 24 to 72 hours."
In addition to sore throat, signs and symptoms frequently associated with streptococcal pharyngitis include fever with temperature greater than 100.4°F (38°C), tonsillar exudates, and cervical adenopathy. Viral pharyngitis is more likely than streptococcal pharyngitis to be associated with cough, coryza, and diarrhea.
The gold standard for streptococcal pharyngitis is throat culture. However, there have been significant improvements in sensitivity and specificity of rapid antigen detection testing (RADT). To facilitate management, the modified Centor score can help clinicians determine which patients should need no testing, throat culture/RADT, or empiric treatment with antibiotics.
The Centor clinical decision rule allowing clinicians to determine appropriate management of patients with sore throat assigns 1 point for each of the following: absence of cough, swollen and tender anterior cervical nodes, elevated temperature of more than 100.4°F (38°C), tonsillar exudates or swelling, and ages 3 to 14 years. One point is subtracted for age 45 years and older.
For a score of 0 to 1, the risk for GABHS pharyngitis is 1% to 2.5% (score ≤ 0) or 5% to 10% (score 1), and no further testing or antibiotics are indicated, although throat culture or RADT may be performed for a score of 1. Other factors should be considered, such as recent family contact with documented streptococcal infection, which would lower the threshold for testing and/or treatment.
For a score of 2 or 3, the risk for GABHS pharyngitis is 11% to 18% (score 2) up to 28% to 35% (score 3), and throat culture or RADT should be performed and antibiotics given if culture results are positive.
For a score of 4 or more, the risk for GABHS pharyngitis is 51% to 53%, and empiric treatment with antibiotics should be considered.
"Although GABHS pharyngitis is common, the ideal approach to management remains a matter of debate," the review authors write. "U.S. guidelines differ in whether they recommend using clinical prediction models versus diagnostic testing. Several international guidelines recommend not testing for or treating GABHS pharyngitis at all."
Complications of GABHS pharyngitis may be either suppurative or nonsuppurative. The suppurative complications may include bacteremia, cervical lymphadenitis, endocarditis, mastoiditis, meningitis, otitis media, peritonsillar or retropharyngeal abscess, and/or pneumonia. Nonsuppurative complications may include poststreptococcal glomerulonephritis or rheumatic fever.
The treatment of choice for streptococcal pharyngitis is penicillin (10 days of oral treatment or 1 injection of intramuscular benzathine penicillin) because of cost, narrow spectrum of activity, and efficacy. However, amoxicillin tastes better and is equally effective. In patients with penicillin allergy, reasonable options are erythromycin and first-generation cephalosporins.
There have been reports of increased GABHS treatment failure with penicillin. Therefore, some guidelines recommend use of cephalosporins in all nonallergic patients, and not just in persons with penicillin allergy, because of improved eradication of GABHS and greater efficacy against chronic carriage of GABHS.
Despite appropriate antibiotic treatment, chronic GABHS colonization is common. There is generally no need to treat chronic carriers because they are thought to be at low risk of transmitting disease or developing invasive GABHS infections.
Persons or situations in which antibiotic treatment of chronic GABHS colonization may be appropriate include recurrent GABHS infection within a family; personal history of or close contact with a person with acute rheumatic fever or acute poststreptococcal glomerulonephritis; close contact with a person with group A streptococcal infection; community outbreak of acute rheumatic fever, poststreptococcal glomerulonephritis, or invasive group A streptococcal infection; healthcare workers or patients in hospitals, chronic care facilities, or nursing homes; families who cannot be reassured without antibiotic treatment; and children who are at risk for tonsillectomy for repeated GABHS pharyngitis.
It is still unclear whether tonsillectomy or adenoidectomy reduces the incidence of GABHS pharyngitis, but the potential benefits are thought to be too small to outweigh the associated costs and surgical risks.
Specific clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:
* Use of clinical decision rules to diagnose GABHS pharyngitis is associated with better quality of care, less unnecessary treatment, and lower overall cost (level of evidence, A).
* In persons who are not penicillin-allergic, penicillin is the treatment of choice for GABHS pharyngitis (level of evidence, A).
* Chronic carriers of pharyngeal GABHS typically do not require treatment (level of evidence, C).
"Differences in guidelines are best explained by whether emphasis is placed on avoiding inappropriate antibiotic use or on relieving acute GABHS pharyngitis symptoms," the review authors conclude. "Several U.S. guidelines recommend confirmatory throat culture for negative RADT in children and adolescents."
Dr. Choby is an assistant editor of The Core Content Review of Family Medicine.
Am Fam Physician. 2009;79:383-390.
Management of Streptococcal Pharyngitis Reviewed CME/CE
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Disclosures
Release Date: March 10, 2009; Valid for credit through March 10, 2010
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians;
Nurses - 0.25 ANCC contact hours (0.25 contact hours are in the area of pharmacology)
To participate in this internet activity: (1) review the target audience, learning objectives, and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation; (4) view/print certificate View details.
Learning Objectives
Upon completion of this activity, participants will be able to:
1. Describe the prevalence, presentation, and diagnosis of group A beta-hemolytic streptococcus pharyngitis.
2. Describe treatment and follow up guidelines for acute, chronic, and recurrent group A beta-hemolytic streptococcus pharyngitis
Authors and Disclosures
Laurie Barclay, MD
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
Désirée Lie, MD, MSEd
Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.
Laurie Scudder, MS, NP
Disclosure: Laurie Scudder, MS, NP, has disclosed no relevant financial information.
Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.
March 10, 2009 — Best practices to diagnose and treat streptococcal pharyngitis in the primary care setting are reviewed in an article published in the March 1 issue of American Family Physician.
"Pharyngitis is diagnosed in 11 million patients in U.S. emergency departments and ambulatory settings annually," writes Beth A. Choby, MD, from University of Tennessee College of Medicine in Chattanooga. "Group A beta-hemolytic streptococcus (GABHS), the most common bacterial etiology, accounts for 15 to 30 percent of cases of acute pharyngitis in children and 5 to 20 percent in adults....The infection is transmitted via respiratory secretions, and the incubation period is 24 to 72 hours."
In addition to sore throat, signs and symptoms frequently associated with streptococcal pharyngitis include fever with temperature greater than 100.4°F (38°C), tonsillar exudates, and cervical adenopathy. Viral pharyngitis is more likely than streptococcal pharyngitis to be associated with cough, coryza, and diarrhea.
The gold standard for streptococcal pharyngitis is throat culture. However, there have been significant improvements in sensitivity and specificity of rapid antigen detection testing (RADT). To facilitate management, the modified Centor score can help clinicians determine which patients should need no testing, throat culture/RADT, or empiric treatment with antibiotics.
The Centor clinical decision rule allowing clinicians to determine appropriate management of patients with sore throat assigns 1 point for each of the following: absence of cough, swollen and tender anterior cervical nodes, elevated temperature of more than 100.4°F (38°C), tonsillar exudates or swelling, and ages 3 to 14 years. One point is subtracted for age 45 years and older.
For a score of 0 to 1, the risk for GABHS pharyngitis is 1% to 2.5% (score ≤ 0) or 5% to 10% (score 1), and no further testing or antibiotics are indicated, although throat culture or RADT may be performed for a score of 1. Other factors should be considered, such as recent family contact with documented streptococcal infection, which would lower the threshold for testing and/or treatment.
For a score of 2 or 3, the risk for GABHS pharyngitis is 11% to 18% (score 2) up to 28% to 35% (score 3), and throat culture or RADT should be performed and antibiotics given if culture results are positive.
For a score of 4 or more, the risk for GABHS pharyngitis is 51% to 53%, and empiric treatment with antibiotics should be considered.
"Although GABHS pharyngitis is common, the ideal approach to management remains a matter of debate," the review authors write. "U.S. guidelines differ in whether they recommend using clinical prediction models versus diagnostic testing. Several international guidelines recommend not testing for or treating GABHS pharyngitis at all."
Complications of GABHS pharyngitis may be either suppurative or nonsuppurative. The suppurative complications may include bacteremia, cervical lymphadenitis, endocarditis, mastoiditis, meningitis, otitis media, peritonsillar or retropharyngeal abscess, and/or pneumonia. Nonsuppurative complications may include poststreptococcal glomerulonephritis or rheumatic fever.
The treatment of choice for streptococcal pharyngitis is penicillin (10 days of oral treatment or 1 injection of intramuscular benzathine penicillin) because of cost, narrow spectrum of activity, and efficacy. However, amoxicillin tastes better and is equally effective. In patients with penicillin allergy, reasonable options are erythromycin and first-generation cephalosporins.
There have been reports of increased GABHS treatment failure with penicillin. Therefore, some guidelines recommend use of cephalosporins in all nonallergic patients, and not just in persons with penicillin allergy, because of improved eradication of GABHS and greater efficacy against chronic carriage of GABHS.
Despite appropriate antibiotic treatment, chronic GABHS colonization is common. There is generally no need to treat chronic carriers because they are thought to be at low risk of transmitting disease or developing invasive GABHS infections.
Persons or situations in which antibiotic treatment of chronic GABHS colonization may be appropriate include recurrent GABHS infection within a family; personal history of or close contact with a person with acute rheumatic fever or acute poststreptococcal glomerulonephritis; close contact with a person with group A streptococcal infection; community outbreak of acute rheumatic fever, poststreptococcal glomerulonephritis, or invasive group A streptococcal infection; healthcare workers or patients in hospitals, chronic care facilities, or nursing homes; families who cannot be reassured without antibiotic treatment; and children who are at risk for tonsillectomy for repeated GABHS pharyngitis.
It is still unclear whether tonsillectomy or adenoidectomy reduces the incidence of GABHS pharyngitis, but the potential benefits are thought to be too small to outweigh the associated costs and surgical risks.
Specific clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:
* Use of clinical decision rules to diagnose GABHS pharyngitis is associated with better quality of care, less unnecessary treatment, and lower overall cost (level of evidence, A).
* In persons who are not penicillin-allergic, penicillin is the treatment of choice for GABHS pharyngitis (level of evidence, A).
* Chronic carriers of pharyngeal GABHS typically do not require treatment (level of evidence, C).
"Differences in guidelines are best explained by whether emphasis is placed on avoiding inappropriate antibiotic use or on relieving acute GABHS pharyngitis symptoms," the review authors conclude. "Several U.S. guidelines recommend confirmatory throat culture for negative RADT in children and adolescents."
Dr. Choby is an assistant editor of The Core Content Review of Family Medicine.
Am Fam Physician. 2009;79:383-390.
# posted by roodbont @ 9:08 AM 
