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Linder, Jeffrey

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    Evaluation and Treatment of Pharyngitis in Primary Care Practice
    (American Medical Association (AMA), 2006-07-10) Linder, Jeffrey; Chan, Joseph C.; Bates, David
    Background The guidelines from the American College of Physicians and the Infectious Diseases Society of America differ with respect to the use of clinical criteria and microbiologic testing to identify adults with pharyngitis who are likely to have group A β-hemolytic streptococci. Methods To measure the rate of adherence to 3 strategies, we performed a retrospective analysis of visits to Boston, Mass, area primary care clinics by adults with a diagnosis of pharyngitis (n = 2097). Results The 4-point Centor criteria recommended by the American College of Physicians and Infectious Diseases Society of America were not predictive of streptococcal testing (results for 0, 1, 2, 3, and 4 criteria were 79%, 81%, 79%, 80%, and 74%, respectively; P = .63) but were predictive of a positive streptococcal test (8%, 13%, 22%, 31%, and 30%, respectively; P<.001) and of antibiotic prescribing (25%, 34%, 63%, 80%, and 89%, respectively; P<.001). Clinicians were adherent to the American College of Physicians' empirical strategy in 12% of visits, the American College of Physicians' test strategy in 30% of visits, the Infectious Diseases Society of America's strategy in 30% of visits, and adherent to none of these strategies in 66% of visits. The most common reason for nonadherence to any strategy was testing or antibiotic prescribing to patients at low risk of streptococcal pharyngitis (1076 visits; 78% of the visits in which physicians were nonadherent to any strategy), patients for whom the guidelines agree. Conclusions The major problem in the testing and treatment of adults with pharyngitis is not which guideline to follow, but that clinicians usually fail to follow any guideline. Interventions should focus on an area where the guidelines agree: avoiding testing and antibiotic prescribing to patients at low risk for streptococcal pharyngitis. Every year, patients in the United States make about 11 million visits to ambulatory practices and emergency departments that result in a diagnosis of pharyngitis.1,2 Approximately 10% of adults with pharyngitis will have group A β-hemolytic streptococci (streptococcal pharyngitis), the only common cause of pharyngitis that warrants antibiotic treatment.3,4 However, about 70% of adults with pharyngitis are treated with antibiotics in the United States.5,6 There is agreement that the antibiotic prescribing rate for adults with pharyngitis is too high, but there is open disagreement as to the optimal way to evaluate and treat adults with pharyngitis.7,8 The American College of Physicians (ACP), the American Academy of Family Practice, and the Centers for Disease Control and Prevention recommend the use of the Centor criteria in the evaluation of adults with pharyngitis.9,10 The 4-point Centor criteria are (1) subjective or objective fever, (2) absence of cough, (3) tender anterior cervical lymphadenopathy, and (4) tonsillar exudates.11 The ACP, American Academy of Family Practice, and Centers for Disease Control and Prevention guideline recommends 2 potential strategies: (1) empirical treatment of patients who meet 3 or 4 Centor criteria (ACP empirical strategy) or (2) testing patients with 2 or 3 criteria using a rapid antigen detection test (RADT) and prescribing antibiotics to patients with a positive test or with 4 criteria (ACP test strategy). The Infectious Diseases Society of America (IDSA) guideline agrees with the ACP guideline that adults with 0 or 1 Centor criteria, who are at low risk for streptococcal pharyngitis, should neither be tested nor treated with antibiotics. In contrast to the ACP strategies, the IDSA12 recommends microbiologic confirmation for all adults with pharyngitis prior to antibiotic prescribing. The authors of the IDSA guideline have been openly critical of the ACP guideline owing to concern that the use of clinical criteria results in the overprescribing of antibiotics to patients who are unlikely to have streptococcal pharyngitis.7,8 To determine if clinicians in actual practice use clinical criteria or microbiologic testing, or both, in the evaluation of adults with pharyngitis, we performed a retrospective review of visits by patients with pharyngitis to clinics in the Brigham and Women's Primary Care (BWPC) Practice-Based Research Network (PBRN) in the greater Boston, Mass, area. We measured adherence to the ACP and IDSA guidelines and calculated hypothetical streptococcal testing rates and antibiotic treatment rates, assuming perfect adherence to each strategy.