Strep throat - Point-Of-Care-Guides

Author: Mark H. Ebell
Date: Sept 1, 2003

Applying the Evidence: Justin is a 13-year-old boy who has had sore throat, fever, and swollen glands for two days. On examination, he has exudative tonsillitis and tender anterior cervical nodes, but no posterior cervical adenopathy. What is his probability of having strep throat?

Answer: Justin has a strep score of 5, which indicates a 52 percent risk of GABHS pharyngitis. It would be reasonable to treat him empirically. As another option, the physician could obtain a specimen for throat culture and call the patient in two days to discontinue the antibiotics if the culture is negative; however, the physician should consider the possibility of false-negative culture results when the pretest probability of strep throat is sufficiently high. A third option is to base treatment on a rapid step test for high-risk patients, although the physician should keep in mind that this test has the same risk of false-negative results as the throat culture.

Clinical Question

What is the probability of group A beta-hemolytic streptococcal (GABHS) pharyngitis (strep throat) in a patient who presents with sore throat?

Evidence Summary

The probability of GABHS pharyngitis as the cause of sore throat is greatest in children younger than 15 years, especially those younger than 10. In a typical outpatient setting, 30 percent of children five to nine years of age with sore throat have GABHS pharyngitis; the probability declines to 15 to 20 percent in preadolescents and adolescents (ages 10 to 19 years). Only 5 to 10 percent of adults with sore throat have GABHS pharyngitis. (1-3)

Signs and symptoms that help rule in GABHS pharyngitis include tonsillar exudates (positive likelihood ratio [LR+]: 3.4), pharyngeal exudates (LR+: 2.1), and exposure to strep throat in the previous two weeks (LR+: 1.9). The absence of tender anterior cervical nodes (negative likelihood ratio [LR-]: 0.6), the absence of tonsillar enlargement (LR-: 0.6), and the absence of exudate (LR-: 0.7) are the most helpful findings for ruling out GABHS pharyngitis. (4) The presence of a scarlatiniform rash or palatine petechiae is uncommon but very specific for the diagnosis of GABHS pharyngitis. (4)

A number of clinical decision rules have been developed and validated to help physicians more accurately estimate the probability of GABHS pharyngitis. Some have been tested only in adults, some only in children, some only in primary care settings, and some only in emergency departments or college health centers. The spectrum of disease may differ in each setting. The best clinical decision rule, created by McIsaac and colleagues, (3) is included in the accompanying evidence-based patient encounter form for the management of sore throat. This tool is simple to use and takes the patient's age, tonsillar exudates, absence of cough, cervical adenopathy, and fever into account. It has been found to be clinically accurate in a group of more than 600 adults and children who presented to family physicians with sore throat. (3)

This article is one in a series that offers evidence-based tools to assist family physicians in improving their decision making at the point of care. The series is published in partnership with Family Practice Management. A related article, which also includes the sore throat encounter form, appears in the September issue of FPM, pages 68-9.

Sore Throat Encounter FormPatient's name: -----Age: -----Medical record #: -----Data collection:Symptom Points| History of fever or measured 1 temp > 100.4 F| Absence of cough 1| Tender anterior cervical nodes 1| Tonsillar swelling or exudates 1Patient's age| <15 years 1| 15 to 45 years 0| >45 years -1Total:Score:0 to -1 point: Strep throat ruled out(only a 2% risk).1 to 2 points: Order rapid strep test;treat accordingly.4 to 5 points: Diagnose probable strepthroat (52% risk); consider empiricantibiotic therapy.Suggestive findings Diagnostic considerations(cross out if negative)| Palatine petechiae or Probable strep throatscarlatiniform rash| Contact with strep infection Consiter strep throat in past 2 weeks| Duration of illness <3 days| Headache Consider meningitis| Stiff neck| Petechial rash| Hot potato voice Consider abscess| Sudden/severe symptoms| Posterior cervical adenopathy Consider mononucleosis or teenagerRapid strep test: | Positive | Negative | NAMono spot test: | Positive | Negative | NAOther history: -----Diagnosis:| Probable or confirmed strep throat -----| Viral pharyngitis -----| Mononucleosis -----| Other: -----Antibiotic treatment:| None needed| Penicillin V potassium| Cephalexin| Erythromycin| AzithromycinSymptomatic measures:| NSAID 12% lidocaine gargle| Sore throat spary | Salt water garglesFollow-up visit:| pm only| ----- daysOther treatment: -----| Patient education handout given.

Developed by Mark H. Ebell, M.D., M.S., Michigan State University College of Human Medicine, East Lansing. Copyright [c] 2003 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. "Point-of-Care Guides." Ebell MH. American Family Physician. September 1, 2003;68:937-8, www.aafp.org/afp/20030901/pocform.html.

REFERENCES

(1.) Komaroff AL, Pass TM, Aronson MD, Ervin CT, Cretin S, Winickoff RN, et al. The prediction of streptococcal pharyngitis in adults. J Gen Intern Med 1986;1:1-7.

(2.) Hoffman S. An algorithm for a selective use of throat swabs in the diagnosis of group A streptococcal pharyngo-tonsillitis in general practice. Scand J Prim Health Care 1992;10:295-300.

(3.) McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ 2000;163:811-5.

(4.) Ebell MH, Smith MA, Barry HC, Ives K, Carey M. The rational clinical examination. Does this patient have strep throat? JAMA 2000;284:2912-8.

Mark H. Ebell, M.D., M.S., Athens, Georgia

Mark H. Ebell, M.D., M.S., is in private practice in Athens, Ga., and is associate professor in the Department of Family Practice at Michigan State University College of Human Medicine, East Lansing. He is also deputy editor for evidence-based medicine of American Family Physician.

Address correspondence to Mark H. Ebell, M.D., M.S., 330 Snapfinger Dr., Athens, GA 30605 (e-mail: ebell@msu.edu). Reprints are not available from the author.

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