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[Streptococcal pharyngitis: clinical suspicion versus diagnosis]
Sofia Morais1, Andreia Teles, Elmano Ramalheira
1Serviço de Pediatria. Hospital Pediátrico de Coimbra. Coimbra.
Insights
Differentiating viral from streptococcal pharyngitis is challenging. Clinical signs alone are unreliable for diagnosis, highlighting the need for diagnostic tests to guide appropriate antibiotic use and avoid unnecessary treatments.
Area of Science:
- Pediatrics
- Infectious Diseases
- Microbiology
Context:
- Pharyngitis is a common illness in ambulatory care.
- Accurate diagnosis is crucial for differentiating viral from streptococcal causes.
- Distinguishing between these causes presents a diagnostic challenge.
Purpose:
- To evaluate the accuracy of clinical characteristics in diagnosing streptococcal pharyngitis in children.
- To compare clinical suspicion with culture-based diagnosis.
- To assess the frequency of false diagnoses and unnecessary antibiotic prescriptions.
Summary:
- 158 children with pharyngitis were evaluated using clinical data and throat cultures.
- Streptococcus pyogenes was present in 43% of cases.
- Clinical signs like scarlatiniform rash, palatal petechiae, and cough showed predictive value, but distinctions remained challenging.
- 37% of diagnoses were false, indicating potential for overtreatment or undertreatment.
Impact:
- Clinical assessment alone is insufficient for accurate pharyngitis diagnosis.
- Diagnostic tests are essential to prevent unnecessary antibiotic use.
- Accurate diagnosis ensures appropriate treatment for streptococcal pharyngitis.
Introduction:
Pharyngitis is a very prevalent illness in the ambulatory care setting. Its diagnosis is a challenge, especially in the differentiation between the viric and streptococcal causes.
Materials And Methods:
A formulary was made to register the clinical and laboratory data; a throat swab for culture was obtained from all the children who presented to the emergency department with sore throat and/or signs of pharyngitis/tonsillitis, for a period of three months (15th of April to 15th of July of 2006). The signs and symptoms, prescribed antibiotherapy and frequency of false diagnostics were evaluated and the clinical suspicion compared with the diagnosis by culture.
Results:
158 children were evaluated, with a median age of four years, with a male predominance (56%). The period that showed the greatest number of cases was the first fifteen days of May. Forty-three percent of the cultures were positive for Streptococcus pyogenes. The more frequent signs and symptoms in pharyngitis were pharyngeal erythema (98%), fever (86%) and sore throat (78%). A significative statistical difference was found for cough, scarlatiniform rash, tonsillar exudate, palatal petechiae and tonsillar swelling. Of the signs and symptoms studied, only three of them presented a positive predictive value superior to 50%: scarlatiniform rash (85%), palatal petechiae (63%) and cough (57%). The presence of tonsillar exudate had a positive predictive value for non-streptococcal pharyngitis of 70%. Fifty-three percent of the doctors considered streptococcal pharyngitis highly probable, and from this, 56% had a positive culture for Streptococcus. Those who considered a low probability, the culture was positive in 28%. There were 37% of false diagnosis.
Discussion:
The distinction between streptococcal pharyngitis and non-streptococcal pharyngitis is not always correct when based on clinical characteristics. The use of diagnostic tests is important in order to avoid unnecessary antibiotherapy as well as to allow the correct use in the positive cases.
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