Streptoccocal Pharyngitis and Appropriate use of Antibiotics

Natalie Darro DO, PGY 1 Educator Advocacy October, 2012

What am I advocating for

UNSOM Pediatricians and Pediatric residents influencing the development of antibiotic resistance in our community Controlled use of antibiotics, especially during cold and flu season Strong communication skills with our patients Use of evidence based medicine in our practices. Ultimately research in the community regarding usefulness of antibiotic education

Presentation Objectives
What we as physicians need to know IDSA Guidelines Strep Pharyngitis What our patients need to know Practical application of material for
communication in a clinical setting Resources for clinical settings

Streptococcal Pharyngitis

Causitive organism is pyogenes GAS causes the widest of syndromes of GAS accounts for 15-30% pharyngitis in children Streptoccocos range any bacterium of

Ages 5-11 have highest

incidence

Major rationale for accurate DX and TX is prevention of Acute rheumatic (Scarlet) fever (ARF) and Rheumatic Heart Disease (RHD), Post Streptococcal Glomerular nephritis, and suppurative complications (peritonsillar abscess)

Critical importance of accurate diagnosis

Strep throat is generally a self limited 3-5 day illness

Signs and symptoms of GAS and nonstreptoccal pharyngitis overlap broadly, accurate DX on clinical grounds alone is impossible
With exception of very rare pharyngeal infections (egCorynebacterium diphtheriae, Neisseria gonorrhoeae) antibiotics are of no proven benefit as treatment for acute pharyngitis It is extremely important to exclude GAS pharyngitis to prevent overuse of ABX Inappropriate abx use for URIs including pharyngitis has been a major contributor to the development of antimicrobial resistance

Scarlet fever exanthem: erythematous, diffuse, sandpapery, punctuated by Pastia lines rash concentrated in flexor skin creases, blanches with pressure, spares circumoral. Its important to test only those that meet clinical suspicion as patients can be Strep carriers with concurrent viral pharyngitis, prompting inappropriate use of antimicrobials

AAP Clinical Practice Guidelines

Patients who have a constellation of signs and symptoms suggestive of GAS pharyngitis should be tested for infections: Posterior pharynx swab RADT Culture <3 yo infrequently present with GAS pharyngitis, almost never develop ARF, documentation and treatment is optional Relying solely on clinical suspicion is discouraged

RADT : Rapid Antigen Detection Testing High Specificity 95-98% Sensitivity 70-90% Positive RADT no culture Negative RADT culture

Throat culture is gold standard: 90-95% sensitive

Optimally: rub both tonsils and posterior pharyngeal wall Innoculate on sheep blood agar 37 C x 24 hrs, then 24 hrs room temp small gray-white colonies with zone of beta hemolysis

IDSA 2012 Guidelines

How should the diagnosis of GAS pharyngitis be established? Who should undergo testing for GAS? What are the treatment recommendations for patients with Dx of GAS pharyngitis Should adjunctive therapy with NSAIDS, acetaminophen, or aspirin be used in treatment Is the patient with frequent recurrent episodes of GAS likely to be a chronic pharyngeal carrier?

How should diagnosis GAS pharyngitis be established?

Throat swab with RADT (except with overt viral features) Throat culture for negative RADT, not for positive RADT

Do not have to culture adult negative RADT

Anti-streptococcal antibody titers are NOT recommended

Who should undergo testing for GAS pharyngitis Testing not recommended: acute pharyngitis with signs/symptoms strongly suggest viral Not recommended: Children < 3 yo unless RF of close contact diagnosed Utilize demographic and symptoms to determine yield of testing, clinical scoring can also be helpful Follow up post treatment throat

cultures is not recommended, may consider with suspicion of carrier status, or resistant Strep species

Empiric treatment or diagnostic

testing of asymptomatic household contacts is not recommended

What are the treatment recommendations for patients diagnosed with GAS pharyngitis? Appropriate antibiotic, appropriate dose x 10 days to eradicate the organism from the pharynx: PCN or amoxicillin : narrow spectrum, low SE, low COST!!! Tx of choice PCN allergic: 1st gen cephalosporin x 10 days, clindamycin x 10 days or azithromycin x 5 days

Should adjunctive NSAID therapy by given? Analgesic/antipyretic agent such as tylenol or NSAID is appropriate, aspirin should not be given to children, corticosteroids are not recommended Is the patient with frequent recurrent episodes of GAS pharyngitis likely to be a chronic carrier? >1 laboratory confirmed GAS pharyngitis in close intervals: likely GAS carrier with repeated viral infections Do not generally require antibiotics: unlikely to spread GAS, unlikely to develop complications such as ARF Do not recommend tonsillectomy solely to reduce frequency of GAS pharyngitis

So we know what we as physicians need to know.

What do our patients need to know??

Patients need to know.

That we care about them/their condition That we are trustworthy Education on their level about their condition What are emergency signs/symptoms What the treatments are

Patients need to know

What pharyngitis/URI is What the difference is between causes

Viral vs. bacterial

What we are using to support our clinical decision making regarding their symptoms and visit.

patient communication having therapeutic effect that improves patient health as quantifiably as drugs has been validated by controlled studies?

Communication with our Patient Did you know that : Good Population

What barriers exist to communication with our patients?

Despite evidence indicating that the average length of the patient- physician encounter has not changed significantly in recent years, specific survey data indicate a correlation between patient participation in capitated health plans and shorter office visits. Further, hurdles arising from linguistic and cultural differences, already abundant, will only increase in Medicalcoming information and support years groups found on the Internet, while potentially a great asset in edu- cating and motivating patients toward better health, have many physicians questioning their traditional role as most trusted counselors.

How do we combat those barriers?

During the typical 15- or 20-minute patient-physician encounter: the physician makes nuanced choices regarding the words, questions, silences, tones, and facial expressions he or she chooses These choices either enhance or detract from the overall level of excellence of the physicians delivery of care.

Traps to avoid!!!

How do we combat these barriers?

Assess what the patient already knows Assess what the patient wants to know Be empathetic Slow down Keep it simple Tell the truth Be hopeful Watch the patients body and face

Be prepared for a reaction Be creative Utilize your resources!!!

Ok Natalieif youre so smart how do you explain the difference between a virus and bacteria? Isnt it an innately scientific concept learned by physicians over 8 years of education?

Ha ha ha! Awesome pictures Natalie!

How about resources?

In conclusion.

As we enter flu season it is part of our responsibility to treat pharyngitis appropriately We need to recognize that antibiotic resistance is a serious problem that we play an important role in Im advocating for appropriate use of antibiotics this flu season and hopefully better overall communication and relationships with our patients!!!

How this presentation helps you:

Review of IDSA and AAP guidelines Review of communication pitfalls and strategies Resources for our clinics to facilitate communication during this cold and flu season!

Thank you!!!!

References

Shulman et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America; CID advance access, September 9th, 2012 Shulman ST, Jaggi P, Group A Streptococcal Infections; Pediatrics in Review, Pediatr. Rev. 2006;27;99-105

Traveline JM, Ruchinskas R, DAlonzo GE. Patient-Physician Communication: Why and How; Journal of American Osteopathic Association, Clinical Practice; Vol 105; No 1; January 2005
www.aware.md ; California Medical Association 2013, AWARE; Alliance Working for Antibiotic Resistance Education; Resources for Healthcare Professionals