Point-of-Care Guides

Diagnosis of Streptococcal Pharyngitis



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Am Fam Physician. 2014 Jun 15;89(12):976-977.

Clinical Question

What is the best way to use the clinical examination to diagnose group A beta-hemolytic streptococcal (GABHS) pharyngitis?

Evidence Summary

Sore throat was the chief symptom in 1.3% of all outpatient office visits in 2010, and is even more common in primary care practice.1,2 An Australian study found that among families with at least one child three to 12 years of age, the incidence of sore throat was 33 and 14 episodes per 100 person-years in children and their parents, respectively. These episodes were caused by GABHS bacteria in about 40% of children and 25% of adults.3 Other studies in adults (with or without children) found that rates of GABHS pharyngitis were somewhat lower at 5% to 15% among those presenting to a physician with sore throat.46

A systematic review of studies in children and adults found that tonsillar exudates (positive likelihood ratio [LR+] = 3.4), pharyngeal exudates (LR+ = 2.1), and exposure to someone with strep throat in the previous two weeks (LR+ = 1.9) increase the likelihood of GABHS pharyngitis, whereas the absence of enlarged tonsils (negative likelihood ratio [LR–] = 0.6), the absence of tender cervical adenopathy (LR– = 0.6), and the absence of exudate (LR– = 0.7) decrease the likelihood.7 In children, scarlatiniform rash (LR+ = 3.9), palatine petechiae (LR+ = 2.7), pharyngeal exudates (LR+ = 1.9), vomiting (LR+ = 1.8), and tender cervical adenopathy (LR+ = 1.7) are all associated with GABHS pharyngitis.8

Because individual signs and symptoms have limited value, a number of clinical decision rules have been developed to diagnose GABHS pharyngitis (Table 1).6,912 The Centor score for strep pharyngitis was adapted by adding the patient's age; the adapted version has been validated in adults and children.6,13 A more recent study proposed the FeverPAIN (fever, purulence, attend rapidly, inflamed tonsils, no cough or coryza) score, which has been shown to reduce use of antibiotics by 30% without worsening other outcomes, reduce costs, and reduce antibiotic resistance. The FeverPAIN score was validated for detection of Lancefield groups A, C, and G streptococcus, resulting in somewhat higher percentages of those with strep throat in each risk group.9,10

Table 1.

Clinical Scores for Diagnosing Strep Throat

Parameters Adapted Centor score6 FeverPAIN score*9,10 Steinhoff, 200511 Joachim, 201012

Population

Children and adults in Canada

Children older than 5 years and adults in the United Kingdom

Children in Egypt

Children in Brazil

Score (1 point is given for each item, unless otherwise specified)

Fever (subjective or measured)

Cervical adenopathy

Tonsillar exudate

No cough

Age (1 point for age < 5 years, –1 point for age > 15 years)

Fever (in previous 24 hours)

Purulent tonsils

Attend rapidly (3 days or less)

Inflamed tonsils (severe)

No cough or coryza

Enlarged cervical nodes

No rhinitis

No rash

Age: ≤ 35 months: 1 point; 36 to 59 months: 2 points; > 59 months: 3 points

Add 1 point for each of the following: tender cervical node, headache, petechiae on the palate, abdominal pain, sudden onset (< 12 hours)

Subtract 1 point for each of the following: conjunctivitis, coryza, diarrhea

Interpretation (point/item total and % strep)

Antibiotic therapy

≥ 4 points (55%)

≥ 4 items (65%)

2 or 3 points (32%)

≥ 4 points (41%)

Rapid test or delayed prescription

2 or 3 (29%)

2 or 3 (40%)

3 (26%)

Symptomatic therapy only

≤ 1 (12%)

0 or 1 (18%)

0 or 1 (7%)

≤ 2 (13%)


*—Included Lancefield groups A, C, and G; other scores validated only for detection of group A beta-hemolytic streptococcal pharyngitis.

Information from references 6, and 9 through 12.

Table 1.   Clinical Scores for Diagnosing Strep Throat

View Table

Table 1.

Clinical Scores for Diagnosing Strep Throat

Parameters Adapted Centor score6 FeverPAIN score*9,10 Steinhoff, 200511 Joachim, 201012

Population

Children and adults in Canada

Children older than 5 years and adults in the United Kingdom

Children in Egypt

Children in Brazil

Score (1 point is given for each item, unless otherwise specified)

Fever (subjective or measured)

Cervical adenopathy

Tonsillar exudate

No cough

Age (1 point for age < 5 years, –1 point for age > 15 years)

Fever (in previous 24 hours)

Purulent tonsils

Attend rapidly (3 days or less)

Inflamed tonsils (severe)

No cough or coryza

Enlarged cervical nodes

No rhinitis

No rash

Age: ≤ 35 months: 1 point; 36 to 59 months: 2 points; > 59 months: 3 points

Add 1 point for each of the following: tender cervical node, headache, petechiae on the palate, abdominal pain, sudden onset (< 12 hours)

Subtract 1 point for each of the f

Mark H. Ebell, MD, MS, is associate professor in the Department of Epidemiology and Biostatistics and codirector of the Institute for Evidence-Based Health Professions Education in the College of Public Health at the University of Georgia, Athens.

Author disclosure: No relevant financial affiliations.

Address correspondence to ebell@uga.edu. Reprints are not available from the author.

REFERENCES

1. National Ambulatory Medical Care Survey: 2010 summary tables. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf. Accessed December 24, 2013.

2. Kirkwood CR, Clure HR, Brodsky R, et al. The diagnostic content of family practice: 50 most common diagnoses recorded in the WAMI community practices. J Fam Pract. 1982;15(3):485–492.

3. Danchin MH, Rogers S, Kelpie L, et al. Burden of acute sore throat and group A streptococcal pharyngitis in school-aged children and their families in Australia. Pediatrics. 2007;120(5):950–957.

4. Komaroff AL, Pass TM, Aronson MD, et al. The prediction of streptococcal pharyngitis in adults. J Gen Intern Med. 1986;1(1):1–7.

5. Hoffmann S. An algorithm for a selective use of throat swabs in the diagnosis of group A streptococcal pharyngo-tonsillitis in general practice. Scand J Prim Health Care. 1992;10(4):295–300.

6. McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ. 2000;163(7):811–815.

7. Ebell MH, Smith MA, Barry HC, Ives K, Carey M. The rational clinical examination. Does this patient have strep throat? JAMA. 2000;284(22):2912–2918.

8. Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr. 2012;160(3):487–493.e3.

9. Little P, Hobbs FD, Moore M, et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ. 2013;347:f5806.

10. Little P, Moore M, Hobbs FD, et al. PRISM Investigators. Primary care streptococcal management (PRISM) study: identifying clinical variables associated with Lancefield A β-haemoloytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open. 2013;3:e003943.

11. Steinhoff MC, Walker CF, Rimoin AW, Hamza HS. A clinical decision rule for management of streptococcal pharyngitis in low-resource settings. Acta Paediatr. 2005;94(8):1038–1042.

12. Joachim L, Campos D Jr, Smeesters PR. Pragmatic scoring system for pharyngitis in low-resource settings. Pediatrics. 2010;126(3):e608–e614.

13. Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847–852.

14. Rimoin AW, Hamza HS, Vince A, et al. Evaluation of the WHO clinical decision rule for streptococcal pharyngitis. Arch Dis Child. 2005; 90(10):1066–1070.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision-making at the point of care.

A collection of Point-of-Care Guides published in AFP is available at http://www.aafp.org/afp/poc.



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