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Streptococcal Pharyngitis: Compliance With National Testing Guidelines in a Pediatric Emergency Department
Jennifer M Thompson1, Alicia L Zagel2, Alicen B Spaulding2
1From the Children's Minnesota Department of Pediatric Emergency Medicine.
Insights
Nearly 40% of pediatric group A streptococcal (GAS) tests in emergency departments (EDs) did not follow guidelines, leading to more antibiotic use and return visits. Interventions are needed to reduce unnecessary GAS testing.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Clinical Guidelines Compliance
Background:
- The Infectious Diseases Society of America (IDSA) provides guidelines for group A streptococcal (GAS) pharyngitis testing.
- These guidelines recommend against testing in specific pediatric populations, including those younger than 3 years or with viral infection symptoms.
- Concerns exist regarding the overuse of GAS testing in clinical settings.
Purpose of the Study:
- To evaluate adherence to IDSA guidelines for GAS testing in a pediatric emergency department (ED).
- To identify factors contributing to noncompliance with GAS testing recommendations.
- To assess the outcomes associated with noncompliant GAS testing.
Main Methods:
- A retrospective cohort study analyzed 13,585 pediatric patient encounters undergoing GAS rapid antigen detection testing in urban EDs in 2016.
- Testing was deemed noncompliant if the chief complaint was inconsistent with GAS infection or the patient was younger than 3 years.
- Statistical analyses compared outcomes between compliant and noncompliant testing groups.
Main Results:
- 39% of GAS tests were noncompliant with IDSA guidelines, primarily due to inconsistent chief complaints (67%) and patient age (48%).
- Antibiotics were prescribed in 51% of noncompliant cases.
- Noncompliant testing was associated with higher return encounter rates (13% vs. 10%) and more frequent respiratory diagnoses upon return (60% vs. 45%).
Conclusions:
- A significant proportion of pediatric GAS testing in EDs does not adhere to established guidelines.
- Noncompliant testing is linked to increased antibiotic use and higher rates of patient return visits.
- Interventions are necessary to improve guideline adherence and mitigate potential negative consequences of unnecessary GAS testing.
Objectives:
The Infectious Diseases Society of America (IDSA) guidelines regarding group A streptococcal (GAS) pharyngitis advise against routine testing for patients younger than 3 years, patients without pharyngitis, and patients with symptoms suggesting a viral infection. Group A streptococcal testing may be overused in some clinical settings; thus, we conducted this study to evaluate compliance with the IDSA guidelines in a pediatric emergency department (ED) setting.
Methods:
This retrospective cohort study describes patients younger than 18 years presenting to 2 urban pediatric EDs in 2016 who underwent rapid antigen detection testing for GAS pharyngitis. Testing was classified as noncompliant with the IDSA guidelines if the chief complaint was not indicative of GAS infection and/or the patient age was younger than 3 years. Appropriate nonparametric tests compared groups by IDSA testing compliance status.
Results:
A total of 13,585 patient encounters met inclusion criteria; 5255 (39%) were noncompliant with the IDSA testing guidelines, the majority due to a chief complaint inconsistent with GAS pharyngitis (67%) and secondarily due to the age of younger than 3 years (48%). Among the patients with noncompliant testing, 51% were prescribed an antibiotic, and return encounters were more likely to occur (13% vs 10%, P < 0.001). Return encounters more commonly resulted in respiratory diagnoses in those with noncompliant GAS testing (60% vs 45%, P < 0.001).
Conclusions:
Nearly 40% of all pediatric ED encounters with GAS testing were noncompliant with the IDSA guidelines and were associated with greater return encounter rates. Potential negative outcomes from noncompliant GAS testing include misdiagnosis, inappropriate use of antibiotics, allergic reactions, and loss of school days. Informed interventions to reduce unnecessary GAS testing are warranted.
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