Evaluating the Diagnostic Paradigm for Group A and Non–Group A Streptococcal Pharyngitis in the College Student Population

Abstract

Background Acute pharyngitis is a frequent illness presenting in outpatient settings. Antibiotics are only recommended for bacterial pharyngitis caused by group A β-hemolytic streptococci (GAS); however, infections with non–group A β-hemolytic streptococci (NGAS) have similar clinical presentations and are common in young adult populations. The objective of this study was to analyze the performance of a current (expert) diagnostic algorithm for GAS pharyngitis, the Centor score, and compare it to alternative models developed to predict GAS and NGAS in a college student population. Methods Electronic health records were obtained for all patients who received a streptococcal rapid antigen detection test (RADT) and/or a bacterial throat culture (n = 3963) at a southeastern US university in 2014. Bivariate and multivariable regression models (least absolute shrinkage and selection operator [LASSO] and stepwise-selected) were fitted to assess and compare their diagnostic performances for GAS-positive and NGAS-positive infections. Results Prevalence of GAS was 18.8%. In the subset of RADT-negative patients who received bacterial throat cultures (n = 313), growth of NGAS occurred in 34.8%, with group C streptococci the most frequent isolate. Mean Centor score was higher for NGAS (3.2) vs GAS (2.9) infections (P = .0111). The area under the curve (AUC) for GAS prediction was 0.64 using the Centor score and 0.70 using the LASSO model. For NGAS, the most important features were cough, pharyngeal erythema, tonsillar exudate, and gastrointestinal symptoms (AUC = 0.63). Conclusions GAS and NGAS pharyngitis were indistinguishable among college students in this study utilizing a commonly applied decision score. Alternative models using additional clinical criteria may be useful for supporting diagnosis of this common illness.

Systematic review and meta-analysis of the accuracy of McIsaac and Centor score in patients presenting to secondary care with Pharyngitis

“…Title and abstract screening identified 163 potentially relevant records of which 15 were included in the review (Figure 1). Of 15 included studies, eight evaluated McIsaac score (30-37) and seven Centor score (38-43). No studies evaluated both scores.…”

“…Six studies have been conducted in the USA, two in Japan, and the rest in Egypt, Greece, Australia, Brazil, Croatia, Latvia, France and Pakistan (Table 1). Ten studies used both RADTs and throat cultures (30-35, 38, 39, 42, 43) as the reference standard: throat culture performed depending on RADT results (32, 35, 38, 43), or both tests performed (30, 31, 33, 34, 39, 42). Two studies (36, 41) only used RADT, and two studies (37, 40) only used throat cultures as the reference standard.…”

“…Two studies (36, 41) only used RADT, and two studies (37, 40) only used throat cultures as the reference standard. Across Centor studies there were 7400 patients in total, of which Rich et al(43) and Rimoin and colleagues (44) contributed 3963 and 2472 patients respectively. A total of 4281 patients were included for the McIsaac score, with similar sample sizes across these eight studies.…”