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Adherence to guidelines for testing and treatment of children with pharyngitis: a retrospective study
Thea Brennan-Krohn1, Al Ozonoff2, Thomas J Sandora3
1Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA. thea.brennan-krohn@childrens.harvard.edu.
Insights
Many children with pharyngitis receive unnecessary antibiotics. While most Group A Streptococcus (GAS) tests are indicated, guidelines for antibiotic use are not always followed, highlighting a need for better antimicrobial stewardship in pediatric care.
Area of Science:
- Pediatrics
- Infectious Diseases
- Clinical Guideline Adherence
Background:
- Group A Streptococcus (GAS) is a common cause of bacterial pharyngitis, often clinically indistinguishable from viral pharyngitis.
- Early antibiotic treatment for GAS pharyngitis is beneficial, but unnecessary antibiotic use for viral pharyngitis is costly and ineffective.
Purpose of the Study:
- To evaluate adherence to clinical guidelines for distinguishing viral from GAS pharyngitis and guiding management.
- To assess the appropriate use of antibiotics in pediatric pharyngitis cases.
Main Methods:
- Retrospective cohort study of patients aged 3-18 undergoing rapid strep testing or throat culture.
- Data collected on McIsaac score components; tests classified as indicated if score was ≥2.
- Antibiotic prescriptions evaluated for indication based on McIsaac score and GAS test results per Infectious Diseases Society of America guidelines.
Main Results:
- Only 30% of eligible children had all McIsaac score components documented.
- 96% of GAS tests were indicated when sufficient data was available to classify the score.
- 28% of antibiotic prescriptions for pharyngitis were not indicated according to guidelines.
Conclusions:
- Most GAS diagnostic tests in children with pharyngitis are indicated.
- Providers frequently do not document all elements of validated pharyngitis scoring tools.
- A significant proportion of antibiotic prescriptions for pharyngitis are not indicated, emphasizing the need for antimicrobial stewardship education.
Background:
Group A streptococcus (GAS) is the most common bacterial etiology of pharyngitis but is difficult to distinguish clinically from viral pharyngitis. There are benefits to early antibacterial treatment of GAS pharyngitis, but administering antibiotics to children with viral pharyngitis is ineffective and costly. We evaluated adherence to guidelines that were developed to help clinicians distinguish between viral and GAS pharyngitis and guide management.
Methods:
Retrospective cohort study of patients ages 3-18 who had a rapid streptococcal test and/or throat culture performed in an outpatient setting. We collected data on documentation of components of the McIsaac score and classified tests as indicated if the score was ≥2. Based on McIsaac score and GAS test results, we determined whether each antibiotic course prescribed was indicated according to the Infectious Diseases Society of America guideline.
Results:
Among 291 eligible children, 87 (30%) had all five components of the McIsaac score documented. There was sufficient data to classify the score as either < 2 or ≥2 in 234 (80%); among these, 96% of tests were indicated. Twenty-nine patients (10%) were prescribed antibiotics. Eight (28%) of these prescriptions were not indicated according to guidelines.
Conclusions:
The majority of GAS tests in children with pharyngitis are indicated, although providers do not regularly document all elements of a validated pharyngitis scoring tool. Over one quarter of children prescribed antibiotics for pharyngitis did not require antibiotics according to guidelines. There remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings.
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