A Simple Scorecard for the Tentative Diagnosis of Streptococcal Pharyngitis

Breese, Burtis B.

doi:10.1001/archpedi.1977.02120180028003

Cited by 108 publications

(89 citation statements)

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“…[24][25][26] The case report form collected information on age, gender, current smoking status and past history of quinsy 27 as well as data on symptom severity for the symptoms of sore throat, difficulty swallowing, fever, cough, coryza ('runny nose'), headache, muscle ache, abdominal pain, diarrhoea, vomiting, earache (each symptom was rated by the patient as follows: 0 = no problem, 1 = slight problem, 2 = moderately bad problem, 3 = severe problem). The doctor or nurse documented examination findings for oral temperature using Tempa•DOT™ thermometers (3M, St Paul, MN, USA) 28 the severity of tonsillar and pharyngeal inflammation, and the presence of cervical glands, tonsillar exudate, fetor and palatal oedema.…”

Section: Clinical Datamentioning

confidence: 99%

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Little

Hobbs

Moore

et al. 2014

Health Technol Assess

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Background Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. Objective This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. Design The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. Setting The setting was UK primary care general practices. Participants Participants were patients aged ≥ 3 years with acute sore throat. Interventions An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. Main outcome measures The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2–4 days). Results The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (–0.33; 95% confidence interval –0.64 to –0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (–0.30; –0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals’ concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. Conclusions Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals’ concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians’ perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed. Trial registration Current Controlled Trials ISRCTN32027234. Source of funding This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 6. See the NIHR Journals Library website for further project information.

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Section: Clinical Datamentioning

confidence: 99%

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Little

Hobbs

Moore

et al. 2014

Health Technol Assess

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“…Many algorithms 23,24 and scores 30,31 have been devised in an attempt to increase the clinical accuracy of the diagnosis of GABHS pharyngitis in children. However, utility of these clinical tools has been limited due to their complexity.…”

Section: Discussionmentioning

confidence: 99%

“…However, utility of these clinical tools has been limited due to their complexity. 23,24,30,31 On the other hand, much simplified clinical guidelines such as the ones produced by the World Health Organization for use by health care professionals in developing countries have been shown to have low sensitivity. 32 Our data have enabled us to devise a clinical decision making chart (Fig.…”

Section: Discussionmentioning

confidence: 99%

Multivariate Predictive Models for Group A Beta‐hemolytic Streptococcal Pharyngitis in Children

Attia

Zaoutis

Eppes

et al. 1999

Academic Emergency Medicine

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Abstract. Objectives:To create predictive models for the clinical diagnosis of group A beta-hemolytic streptococcal (GABHS) pharyngitis in children. Methods: Patients aged 6 months to 18 years presenting to a pediatric ED with suspected GABHS pharyngitis were prospectively enrolled in the study. Clinicians recorded pertinent clinical information using a standardized form and obtained a throat swab to culture GABHS using a reference standard method. Twelve demographic and clinical features of patients with positive throat cultures were compared with the features of patients with negative throat cultures. Significantly different features were entered in a stepwise logistic regression analysis to create predictive models for the diagnosis. Results: Eighty-five patients (29%) were culture-positive and 212 (71%) were culture-negative for GABHS. Respective mean ages were 6.2 years and 6.1 years in the two groups. Univariate chi-square analysis of the 12 features identified six variables that were significantly associated with GABHS. All significant features were initially included in a stepwise logistic regression analysis. In model I, four independent variables were identified: moderate to severe presentation of tonsillar swelling, moderate to severe tenderness and enlargement of cervical lymph nodes, the presence of scarlatiniform rash, and the absence of moderate to severe coryza, yielding a 95% probability for GABHS. Excluding the rare scarlatiniform rash, the remaining variables were used in the second regression analysis. In model II, three independent variables were identified: moderate to severe tonsillar swelling, moderate to severe tenderness and enlargement of cervical lymph nodes, and absence of moderate to severe coryza, yielding a probability of 65% for the diagnosis. A probability of <15% was observed in the absence of scarlatiniform rash, the absence of moderate to severe tenderness and enlargement of cervical lymph nodes, and the presence of moderate to severe coryza. Conclusions: In children with moderate to severe presentation of tonsillar swelling, tenderness and enlargement of cervical lymph nodes, and the absence of coryza, the probability of a positive throat culture is >65%. Conversely, in the absence of a moderate to severe presentation of tonsillar swelling, enlargement of cervical nodes, and the presence of coryza, the probability of a positive throat culture is <15%. If prospectively validated, these models could be integrated into a consistent treat, test, and no treatment/no testing approach to the clinical management of childhood pharyngitis.

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“…18,7,19 The clinical proforma collected information on age; sex; current smoking status; past history of quinsy; 20 data on symptom severity for the symptoms of sore throat, difficulty swallowing, fever, cough, coryza ('runny nose') headache, muscle ache, abdominal pain, diarrhoea vomiting, earache (each symptom was rated by the patient as 0 = no problem, 1 = slight problem, 2 = moderately bad problem, or 3 = severe problem). The doctor or nurse documented examination findings for oral temperature using TempaDOT ™ thermometers, 21 the severity of tonsillar and pharyngeal inflammation, the presence of cervical glands, tonsillar exudate, fetor and palatal oedema.…”

Section: Clinical Datamentioning

confidence: 99%

“…The doctor or nurse documented examination findings for oral temperature using TempaDOT ™ thermometers, 21 the severity of tonsillar and pharyngeal inflammation, the presence of cervical glands, tonsillar exudate, fetor and palatal oedema. 7,18,19 Throat swabs. At the training session in each practice clinicians were instructed in standard study procedures, including how to take a throat swab.…”

Section: Clinical Datamentioning

confidence: 99%

Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study

Little¹,

Hobbs²,

Mant³

et al. 2012

Br J Gen Pract

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A Simple Scorecard for the Tentative Diagnosis of Streptococcal Pharyngitis

Cited by 108 publications

References 1 publication

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Multivariate Predictive Models for Group A Beta‐hemolytic Streptococcal Pharyngitis in Children

Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study

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