Strep Throat Guidelines Are Frequently Ignored


BOSTON — Many physicians do not follow recommended guidelines for the diagnosis and management of children with pharyngitis, according to results of a Centers for Disease Control and Prevention survey.

Although pharyngitis is one of the most common reasons for prescribing antibiotics for children, only 15%-30% of pediatric episodes are caused by group A streptococci and helped by antibiotics, CDC epidemiologist Sarah Y. Park, M.D., said in a presentation at the annual meeting of the Infectious Disease Society of America.

Numerous studies have demonstrated that it is not possible on clinical grounds to differentiate streptococcal from viral pharyngitis, yet 278 of 505 (55%) eligible pediatricians and family physicians who completed the CDC survey said they did not wait for laboratory confirmation of bacterial pharyngitis before initiating antibiotic therapy.

In addition, 64 (13%) of the respondents said they prescribed antibiotics based on clinical findings alone.

Diagnostic recommendations for pharyngitis are throat culture alone or a rapid antigen-detection test with throat culture backup, in conjunction with clinical and epidemiologic findings, said Dr. Park. “Diagnosis based on clinical findings alone is not recommended. Most physicians tend to overestimate the probability of a streptococcal infection based on history and physical examination, which leads to antibiotic abuse,” she said.

Dr. Park and her colleagues sent surveys to a total of 2,000 randomly selected members of the American Academy of Family Physicians (1,000 recipients) and the American Academy of Pediatrics (1,000 recipients).

The surveys included questions about demographics, management strategies for acute pharyngitis, understanding of the appropriate use of throat cultures and rapid testing, and the approach to a clinical scenario with clinical findings consistent with group A streptococci pharyngitis.

The preliminary results are based on the responses from 260 pediatricians and 245 family physicians.

Approximately 94% of the physicians cited prevention of acute rheumatic fever as a reason to treat bacterial pharyngitis, and 54% cited prevention of acute glomerulonephritis. Rapid antigen detection tests were available to 89% of respondents, and throat culture was available to 93%. Of the 441 physicians who reported using any test, 39 said they continued with antibiotic therapy despite a negative test, “which is why presumptively starting therapy pending results of a culture is discouraged; treatment often continues regardless of the result,” said Dr. Park.

In addition, 52 (13%) of the 388 physicians who reported using the rapid antigen test said they did not confirm a negative result with throat culture, as the clinical guidelines recommend.

The findings are disappointing in light of the growing awareness of the risks of antibiotic overuse and resistance, said Dr. Park. “Accurate diagnosis of group A streptococcal pharyngitis and appropriate antimicrobial therapy are important, particularly to prevent nonsuppurative sequelae such as rheumatic fever. But following recommended guidelines is just as important.”

Toward this end, efforts need to target physician understanding of the appropriate use of throat culture and rapid antigen-detection testing to promote reasonable antibiotic prescribing, she concluded.

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