Diagnostic accuracy of Fever-PAIN and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial

Abstract

BackgroundSore throat is a common and self-limiting condition. There remains ambiguity in stratifying patients to immediate, delayed or no antibiotic prescriptions. NICE recommends two clinical prediction rules (CPRs), FeverPAIN and CENTOR, to guide decision-making.AimDescribe the diagnostic accuracy of CPRs in identifying streptococcal throat infections.Design and SettingAdults presenting to UK primary care with sore throat, who did not require immediate antibiotics.MethodsAs part of the Treatment Options without Antibiotics for Sore Throat (TOAST) trial, 565 participants, aged ≥18, were recruited on day of presentation to general practice. Physicians could opt to give delayed prescriptions. CPR scores were not part of the trial protocol but calculated post-hoc from baseline assessments. Diagnostic accuracy was calculated by comparing scores to throat swab cultures.Results81/502 (16.1%) of patients had Group A, C or G streptococcus cultured on throat swab. Overall diagnostic accuracy of both CPRs was poor: area under receiver-operating-characteristics curve 0.62 for Centor; 0.59 for FeverPAIN. Post-test probability of a positive or negative test was 27.3% (95% confidence intervals: 6.0%–61.0%) and 84.1% (80.6%–87.2%) for FeverPAIN ≥4, vs 25.7% (16.2%–37.2%) and 85.5% (81.8%–88.7%) for Centor ≥3. Higher CPR scores were associated with increased delayed antibiotic prescriptions (χ2=8.42, P=0.004 for FeverPAIN ≥4; χ2=32.0, P<0.001 for Centor ≥3).ConclusionsIn those that do not require immediate antibiotics in primary care, neither CPR provide a reliable way of diagnosing streptococcal throat infection. However, clinicians were more likely to give delayed prescriptions to those with higher scores.

Diagnosis of Epstein-Barr and cytomegalovirus infections using decision trees: an effective way to avoid antibiotic overuse in paediatric tonsillopharyngitis

“…It has already been pointed out that classification on the basis of symptoms is not sufficiently specific even when distinguishing viral infection from bacterial infection (Centor and FeverPAIN scoring) [ 6 ]. Our experimental design is difficult to compare with these findings, given that we did not aim to distinguish between viral and bacterial infections, but one type of viral infection from all others.…”

“…Given the foregoing, it is becoming increasingly important to differentiate between pharyngitis caused by viral and bacterial infection, or to use algorithms that can confidently identify specific viral/bacterial infections). Although the FeverPAIN and Centor scoring methods are widely utilized in clinical practice, their diagnostic accuracy is low due to overlapping symptoms if the patient’s score does not fall into a truly high-risk category [ 6 ].…”

Improvement of antibiotic use in sore throat, tonsillitis and acute otitis media in Palestine: a prospective full cycle audit

“…NICE recommendations and FeverPAIN scores were used for the assessment and management of acute tonsillitis and sore throat. They were used to determine the need for antibiotics, the time to collect antibiotics, and the appropriate antibiotic choice, dosage, frequency and duration [19,37]. The score comprises of five components: getting medical help rapidly within ≤ 3 days, fever ≥ 38°C in the last 24 hours, absence of cough, and evidence of purulence or signs of severe inflammation upon throat examination.…”

Characteristics of the sore throat test and treat service in community pharmacies (STREP) in Wales: cross-sectional analysis of 11 304 consultations using anonymized electronic pharmacy records

“…35 There is new evidence on the low rate of serious complications of upper respiratory tract infections in UK primary care. 39 The above supports changes to the delivery model of STTT for a subgroup of service users, with care to maintain safety as the service relies on a structured service specification. Some suggestions could be: re-consultation in pharmacy; delayed supply of antibiotics; or changing criteria for RADT by increasing the threshold score from FeverPAIN > 1 to FeverPAIN > 2 with a subsequent reduction in testing and prescribing.…”