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Treatment of Adults With Acute Pharyngitis in Primary Care Practice—Reply

Treatment of Adults With Acute Pharyngitis in Primary Care Practice—Reply In reply Bisno and colleagues highlight the rationale for our study,1 though we believe they draw attention away from the major problem in the treatment of adults with pharyngitis by focusing on patients meeting 4 Centor criteria. In our study, these patients made up only 2% of the sample and accounted for only 4% of antibiotic prescribing. Bisno and colleagues have written that “adults who meet none or only 1 of the 4 Centor criteria should not be tested or treated because of the very low probability of streptococcal infection, ”2(p127) a statement that agrees with the ACP guideline. Management of these patients is the major problem, having accounted for 57% of testing and 44% of antibiotic prescribing. Westerman raises several seemingly controversial issues regarding the evaluation of adults with pharyngitis. Group C and G streptococci can cause pharyngitis that mimics GAS pharyngitis. However, group C and G streptococcal pharyngitis are less common, milder, and more rarely cause complications compared with GAS pharyngitis, so the benefit of antimicrobial therapy is less clear.3 Westerman cites pediatric data to raise doubts about the usefulness of the Centor criteria in adults. Because clinical signs and symptoms are more nonspecific in children, guidelines agree in recommending confirmation with a streptococcal test prior to starting antibiotic treatment. We have previously found that physicians nationwide adhere poorly to this recommendation.4 In adults, signs and symptoms of streptococcal pharyngitis are sufficiently specific that clinical criteria are useful, which is again a point on which the ACP and the IDSA agree. Although cephalosporins had higher bacteriological and “clinical cure” rates in adults compared with penicillin in 9 studies, these studies had strict microbiologic inclusion criteria, a high proportion of patients excluded from their analyses, and, as a result, only moderate quality scores; they may not be representative of actual clinical practice. The IDSA, the ACP, the American Academy of Family Practice, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention continue to recommend penicillin as the antibiotic of choice because of its efficacy, safety, narrow spectrum, and low cost. Westerman brings up an important issue in his choice of words, wondering if we should even “treat” patients with streptococcal pharyngitis, as if the only choice is in prescribing or not prescribing antibiotics. Every patient with pharyngitis—streptococcal or not—should be treated with analgesics, antipyretics, and other symptomatic therapies. Whether streptococcal pharyngitis should be treated with antibiotics is a valid question. We stated in our original article “antibiotic treatment of patients with streptococcal pharyngitis reduces the duration of symptoms, limits the spread of streptococci, and reduces suppurative and nonsuppurative complications.”1(p1378-1379) The absolute benefits of antibiotics are modest, and some international guidelines do not recommend the use of antibiotics for pharyngitis, even if GAS is present.5,6 Practitioners in other countries seem to believe that it is unwise to freely prescribe antibiotics just “because we can.” We agree with Irani's point that health information technology can play an important role in the dissemination of guidelines. In particular, electronic health records can integrate guideline-based care into the clinical workflow and make it easy for clinicians to do the right thing.7 These interventions have sometimes but not always been effective; indeed, one of the most important frontiers in medical informatics is how to best bring decision support, including guidelines, to the point of care. Typically, though, major improvement will require both an information- and technology-oriented component and also other components such as education. In the case of pharyngitis, the biggest reductions in antibiotic prescribing will come from solutions that help clinicians avoid testing and antibiotic prescribing to adults at low risk for streptococcal pharyngitis (those meeting 0 or 1 Centor criteria). Correspondence: Dr Linder, Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont St, BC-3-2X, Boston, MA 02120 (jlinder@partners.org). References 1. Linder JAChan JCBates DW Evaluation and treatment of pharyngitis in primary care practice. Arch Intern Med 2006;1661374- 1379PubMedGoogle ScholarCrossref 2. Bisno ALPeter GSKaplan EL Diagnosis of strep throat in adults: are clinical criteria really good enough? Clin Infect Dis 2002;35126- 129PubMedGoogle ScholarCrossref 3. Bisno AL Acute pharyngitis. N Engl J Med 2001;344205- 211PubMedGoogle ScholarCrossref 4. Linder JABates DWLee GMFinkelstein JA Antibiotic treatment of children with sore throat. JAMA 2005;2942315- 2322PubMedGoogle ScholarCrossref 5. The Dutch College of General Practitioners, Practice guideline: acute sore throat. http://nhg.artsennet.nl/upload/104/guidelines2/E11.htm. Accessed February 3, 2005 6. Scottish Intercollegiate Guidelines Network, Management of sore throat and indications for tonsillectomy: a national clinical guideline. http://www.sign.ac.uk/pdf/sign34.pdf. Accessed February 3, 2005 7. Linder JA Health information technology as a tool to improve care for acute respiratory infections. Am J Manag Care 2004;10661- 662PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Treatment of Adults With Acute Pharyngitis in Primary Care Practice—Reply

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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.166.20.2292-a
Publisher site
See Article on Publisher Site

Abstract

In reply Bisno and colleagues highlight the rationale for our study,1 though we believe they draw attention away from the major problem in the treatment of adults with pharyngitis by focusing on patients meeting 4 Centor criteria. In our study, these patients made up only 2% of the sample and accounted for only 4% of antibiotic prescribing. Bisno and colleagues have written that “adults who meet none or only 1 of the 4 Centor criteria should not be tested or treated because of the very low probability of streptococcal infection, ”2(p127) a statement that agrees with the ACP guideline. Management of these patients is the major problem, having accounted for 57% of testing and 44% of antibiotic prescribing. Westerman raises several seemingly controversial issues regarding the evaluation of adults with pharyngitis. Group C and G streptococci can cause pharyngitis that mimics GAS pharyngitis. However, group C and G streptococcal pharyngitis are less common, milder, and more rarely cause complications compared with GAS pharyngitis, so the benefit of antimicrobial therapy is less clear.3 Westerman cites pediatric data to raise doubts about the usefulness of the Centor criteria in adults. Because clinical signs and symptoms are more nonspecific in children, guidelines agree in recommending confirmation with a streptococcal test prior to starting antibiotic treatment. We have previously found that physicians nationwide adhere poorly to this recommendation.4 In adults, signs and symptoms of streptococcal pharyngitis are sufficiently specific that clinical criteria are useful, which is again a point on which the ACP and the IDSA agree. Although cephalosporins had higher bacteriological and “clinical cure” rates in adults compared with penicillin in 9 studies, these studies had strict microbiologic inclusion criteria, a high proportion of patients excluded from their analyses, and, as a result, only moderate quality scores; they may not be representative of actual clinical practice. The IDSA, the ACP, the American Academy of Family Practice, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention continue to recommend penicillin as the antibiotic of choice because of its efficacy, safety, narrow spectrum, and low cost. Westerman brings up an important issue in his choice of words, wondering if we should even “treat” patients with streptococcal pharyngitis, as if the only choice is in prescribing or not prescribing antibiotics. Every patient with pharyngitis—streptococcal or not—should be treated with analgesics, antipyretics, and other symptomatic therapies. Whether streptococcal pharyngitis should be treated with antibiotics is a valid question. We stated in our original article “antibiotic treatment of patients with streptococcal pharyngitis reduces the duration of symptoms, limits the spread of streptococci, and reduces suppurative and nonsuppurative complications.”1(p1378-1379) The absolute benefits of antibiotics are modest, and some international guidelines do not recommend the use of antibiotics for pharyngitis, even if GAS is present.5,6 Practitioners in other countries seem to believe that it is unwise to freely prescribe antibiotics just “because we can.” We agree with Irani's point that health information technology can play an important role in the dissemination of guidelines. In particular, electronic health records can integrate guideline-based care into the clinical workflow and make it easy for clinicians to do the right thing.7 These interventions have sometimes but not always been effective; indeed, one of the most important frontiers in medical informatics is how to best bring decision support, including guidelines, to the point of care. Typically, though, major improvement will require both an information- and technology-oriented component and also other components such as education. In the case of pharyngitis, the biggest reductions in antibiotic prescribing will come from solutions that help clinicians avoid testing and antibiotic prescribing to adults at low risk for streptococcal pharyngitis (those meeting 0 or 1 Centor criteria). Correspondence: Dr Linder, Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont St, BC-3-2X, Boston, MA 02120 (jlinder@partners.org). References 1. Linder JAChan JCBates DW Evaluation and treatment of pharyngitis in primary care practice. Arch Intern Med 2006;1661374- 1379PubMedGoogle ScholarCrossref 2. Bisno ALPeter GSKaplan EL Diagnosis of strep throat in adults: are clinical criteria really good enough? Clin Infect Dis 2002;35126- 129PubMedGoogle ScholarCrossref 3. Bisno AL Acute pharyngitis. N Engl J Med 2001;344205- 211PubMedGoogle ScholarCrossref 4. Linder JABates DWLee GMFinkelstein JA Antibiotic treatment of children with sore throat. JAMA 2005;2942315- 2322PubMedGoogle ScholarCrossref 5. The Dutch College of General Practitioners, Practice guideline: acute sore throat. http://nhg.artsennet.nl/upload/104/guidelines2/E11.htm. Accessed February 3, 2005 6. Scottish Intercollegiate Guidelines Network, Management of sore throat and indications for tonsillectomy: a national clinical guideline. http://www.sign.ac.uk/pdf/sign34.pdf. Accessed February 3, 2005 7. Linder JA Health information technology as a tool to improve care for acute respiratory infections. Am J Manag Care 2004;10661- 662PubMedGoogle Scholar

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 13, 2006

Keywords: primary health care,pharyngitis, bacterial, acute

References