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Acute Pharyngitis: No Reliability of Rapid Streptococcal Tests and Clinical Findings

Acute Pharyngitis: No Reliability of Rapid Streptococcal Tests and Clinical Findings In their article, Humair et al1 recommend the use of the streptococcal test and Centor criteria as valid tests for the diagnosis of pharyngitis in adults. After consulting the Internet guidelines on acute sore throat (see “Additional Information” at the end of this letter), we cannot share their opinion for the following reasons: The Centor criteria (fever ≥38.5°C, absence of cough, tonsillar exudate, and enlarged cervical glands) are only used in 4 guidelines (3 American and 1 Canadian) and not in most of the European guidelines. This is mainly because in the logistic regression analysis that Centor conducted himself, he found that the prevalence of streptococci when 1, 2, 3, and 4 criteria were present were 6.5%, 15%, 32%, and 56%, respectively. Thus, even when the 4 criteria of Centor are present, the chance of a streptococci infection is nearly the same as a coin toss (56%).2 There is no international consensus on the use of the rapid streptococcal test (rapid antigen test): it is recommended in the American guidelines and in 1 European guideline (Finland). The streptococcal test is not recommended in the guidelines of England, Belgium, the Netherlands, Canada, and Scotland. These guidelines state that the predictive value of the test is too low, given the prevalence of streptococcal carriers (between 5% and 20%). Another reason is a modest sensitivity of the streptococcal test (most streptococcal tests have a sensitivity of about 80%-85% in primary health care, but not 90%).3-5 There is no consensus on the use of a throat culture. A throat culture is still recommended in different American guidelines and the Canadian and Finnish guidelines. Cultures are recommended when the streptococcal test result is negative or not commonly available. According to the guidelines of France, the Netherlands, Belgium, England, and Scotland and in 1 American guideline, results from a throat culture arrive too late to significantly influence the clinical course and are therefore not used. In most of the European guidelines, acute sore throat is considered a self-limiting disease, and antibiotics are not commonly recommended. This is in accordance with European randomized clinical trials6 and the Cochrane review. Antibiotics (penicillin) provide only moderate clinical benefits in a minority of patients with pharyngitis, which is a self-limiting disease with low complication rates. Because antibiotics are only reserved for patients at risk (5% or less), there is no need for a streptococcal test in acute pharyngitis. Correspondence: Dr Matthys, General Practice and Primary Health Care, University of Ghent, De Pintelaan 185, Gent 9000, Belgium (jan.matthys@ugent.be). Additional Information: Drs Matthys and De Meyere are authors of the Belgian guideline for acute sore throat. Internet guidelines on acute sore throat can be found at http://nhg.artsennet.nl.(the Netherlands); http://agmed.sante.gouv.fr.(France); http://www.hlth.gov.bc.ca.(Canada); http://www.guideline.gov.(United States); http://www.health.fgov.be.(Belgium); and http://www.sign.ac.uk.(Scotland); http://www.prodigy.nhs.uk.(United Kingdom). References 1. Humair JPRevaz SABovier PStalder H Management of acute pharyngitis in adults. Arch Intern Med 2006;166640- 644PubMedGoogle ScholarCrossref 2. Centor RMWitherspoon JMDalton HPBrody CELink K The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1239- 246PubMedGoogle ScholarCrossref 3. Nerbrand CJasir ASchalen C Are current rapid detection tests for group A streptococci sensitive enough? evaluation of 2 commercial kits. Scand J Infect Dis 2002;34797- 799PubMedGoogle ScholarCrossref 4. Gieseker KEMackenzie TRoe MHTodd JK Comparison of two rapid Streptococcus pyogenes diagnostic tests with a rigorous culture standard. Pediatr Infect Dis J 2002;21922- 927PubMedGoogle ScholarCrossref 5. Van Limbergen JKalima PTaheri SBeattie TF Streptococcus A in paediatric accident and emergency: are rapid streptococcal tests and clinical examination of any help? Emerg Med J 2006;2332- 34PubMedGoogle ScholarCrossref 6. De Meyere MMervielde YVerschraegen GBogaert M Effect of penicillin on the clinical course of streptococcal pharyngitis in general practice. Eur J Clin Pharmacol 1992;43581- 585PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Acute Pharyngitis: No Reliability of Rapid Streptococcal Tests and Clinical Findings

Archives of Internal Medicine , Volume 166 (20) – Nov 13, 2006

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References (11)

Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.166.20.2285-a
Publisher site
See Article on Publisher Site

Abstract

In their article, Humair et al1 recommend the use of the streptococcal test and Centor criteria as valid tests for the diagnosis of pharyngitis in adults. After consulting the Internet guidelines on acute sore throat (see “Additional Information” at the end of this letter), we cannot share their opinion for the following reasons: The Centor criteria (fever ≥38.5°C, absence of cough, tonsillar exudate, and enlarged cervical glands) are only used in 4 guidelines (3 American and 1 Canadian) and not in most of the European guidelines. This is mainly because in the logistic regression analysis that Centor conducted himself, he found that the prevalence of streptococci when 1, 2, 3, and 4 criteria were present were 6.5%, 15%, 32%, and 56%, respectively. Thus, even when the 4 criteria of Centor are present, the chance of a streptococci infection is nearly the same as a coin toss (56%).2 There is no international consensus on the use of the rapid streptococcal test (rapid antigen test): it is recommended in the American guidelines and in 1 European guideline (Finland). The streptococcal test is not recommended in the guidelines of England, Belgium, the Netherlands, Canada, and Scotland. These guidelines state that the predictive value of the test is too low, given the prevalence of streptococcal carriers (between 5% and 20%). Another reason is a modest sensitivity of the streptococcal test (most streptococcal tests have a sensitivity of about 80%-85% in primary health care, but not 90%).3-5 There is no consensus on the use of a throat culture. A throat culture is still recommended in different American guidelines and the Canadian and Finnish guidelines. Cultures are recommended when the streptococcal test result is negative or not commonly available. According to the guidelines of France, the Netherlands, Belgium, England, and Scotland and in 1 American guideline, results from a throat culture arrive too late to significantly influence the clinical course and are therefore not used. In most of the European guidelines, acute sore throat is considered a self-limiting disease, and antibiotics are not commonly recommended. This is in accordance with European randomized clinical trials6 and the Cochrane review. Antibiotics (penicillin) provide only moderate clinical benefits in a minority of patients with pharyngitis, which is a self-limiting disease with low complication rates. Because antibiotics are only reserved for patients at risk (5% or less), there is no need for a streptococcal test in acute pharyngitis. Correspondence: Dr Matthys, General Practice and Primary Health Care, University of Ghent, De Pintelaan 185, Gent 9000, Belgium (jan.matthys@ugent.be). Additional Information: Drs Matthys and De Meyere are authors of the Belgian guideline for acute sore throat. Internet guidelines on acute sore throat can be found at http://nhg.artsennet.nl.(the Netherlands); http://agmed.sante.gouv.fr.(France); http://www.hlth.gov.bc.ca.(Canada); http://www.guideline.gov.(United States); http://www.health.fgov.be.(Belgium); and http://www.sign.ac.uk.(Scotland); http://www.prodigy.nhs.uk.(United Kingdom). References 1. Humair JPRevaz SABovier PStalder H Management of acute pharyngitis in adults. Arch Intern Med 2006;166640- 644PubMedGoogle ScholarCrossref 2. Centor RMWitherspoon JMDalton HPBrody CELink K The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981;1239- 246PubMedGoogle ScholarCrossref 3. Nerbrand CJasir ASchalen C Are current rapid detection tests for group A streptococci sensitive enough? evaluation of 2 commercial kits. Scand J Infect Dis 2002;34797- 799PubMedGoogle ScholarCrossref 4. Gieseker KEMackenzie TRoe MHTodd JK Comparison of two rapid Streptococcus pyogenes diagnostic tests with a rigorous culture standard. Pediatr Infect Dis J 2002;21922- 927PubMedGoogle ScholarCrossref 5. Van Limbergen JKalima PTaheri SBeattie TF Streptococcus A in paediatric accident and emergency: are rapid streptococcal tests and clinical examination of any help? Emerg Med J 2006;2332- 34PubMedGoogle ScholarCrossref 6. De Meyere MMervielde YVerschraegen GBogaert M Effect of penicillin on the clinical course of streptococcal pharyngitis in general practice. Eur J Clin Pharmacol 1992;43581- 585PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 13, 2006

Keywords: pharyngitis, bacterial, acute,streptococcal antigen test, rapid

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