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Identifying Patients at Lowest Risk for Streptococcal Pharyngitis: A National Validation Study
Daniel J Shapiro1, Yuval Barak-Corren2, Mark I Neuman1
1Department of Pediatrics, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
Insights
A new decision rule can identify children with viral illness symptoms who are unlikely to have group A Streptococcus, potentially reducing unnecessary lab tests for pharyngitis.
Area of Science:
- Pediatric infectious diseases
- Clinical decision support
- Epidemiology of respiratory infections
Background:
- Group A Streptococcus (GAS) pharyngitis is common in children.
- Differentiating viral illness from GAS pharyngitis can be challenging.
- Over-testing for GAS contributes to antibiotic overuse.
Purpose of the Study:
- To determine the prevalence of viral illness features in children tested for GAS pharyngitis.
- To develop a decision rule for identifying low-risk patients with viral illness who may avoid GAS testing.
Main Methods:
- Retrospective study of 67,127 electronic health records from retail health clinics.
- Analysis of patients aged 3-21 years evaluated for sore throat.
- Development of a decision tree algorithm to identify low-risk GAS patients.
Main Results:
- 54% of patients presented with features of viral illness.
- A decision rule identified patients without tonsillar exudates, aged 11+, and lacking fever or cervical adenopathy as low-risk for GAS.
- This low-risk group represented 19% of all patients tested for GAS.
Conclusions:
- An objective decision rule can identify patients with viral illness features at low risk for GAS.
- Improved identification can optimize GAS testing and antibiotic prescribing for pharyngitis.
- This approach supports appropriate use of laboratory diagnostics in pediatric sore throat evaluations.
Objectives:
To determine the prevalence of features of viral illness in a national sample of visits involving children tested for group A Streptococcus pharyngitis. Additionally, we sought to derive a decision rule to identify patients with features of viral illness who were at low risk of having group A Streptococcus and for whom laboratory testing might be avoided.
Study Design:
Retrospective validation study using data from electronic health records of patients 3-21 years old evaluated for sore throat in a national network of retail health clinics (n = 67 127). We determined the prevalence of features of viral illness in patients tested for group A Streptococcus and developed a decision tree algorithm to identify patients with features of viral illness at low risk (<15%) of having group A Streptococcus.
Results:
Overall, 54% of patients had features of viral illness. Among patients with features of viral illness, those without tonsillar exudates who were 11 years or older and either lacked cervical adenopathy or had cervical adenopathy and lacked fever were identified as at low risk for group A Streptococcus according to the decision rule. This group comprised 34% of patients with features of viral illness, or 19% of all patients tested for group A Streptococcus infection.
Conclusions:
Our findings provide an objective way to identify patients with features of viral illness who are at low risk of having group A Streptococcus. Improved identification such patients at low risk of group A Streptococcus could improve appropriate testing and antibiotic prescribing for pharyngitis.
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