NR 511 CPG PHARYNGITIS

Disease & Background Student 15: 1) Identifies the disease condition 2) Gives a brief statement of incidence and prevalence in the US. 3) The student briefly summarizes the disease pathophysiology and 4) Identifies the typical clinical presentation seen in a patient with the disease 1 Hello, this is my Clinical Practice Guidelines presentation on Strep Pharyngitis for NR 511. 2 This presentation is going to cover what the disease and background of strep pharyngitis is, how we should be screening for it in primary care and how we need to be managing our patients that have strep pharyngitis. 3 Streptococcal Pharyngitis is known as strep throat, is one of the most common reasons for visit to primary care. Around 11 million people are diagnosed with pharyngitis in the United States every year. The most common among children age 5 through 15 years of age, but rare in children younger than 3 years of age. The bacterial cause of acute pharyngitis is all year around, but most common during the late winter and early spring. Strep Pharyngitis is spread from person to person via saliva or nasal secretion; causes 20-30% of sore throat visits in children and 5-15 % in adults. 4 Strep pharyngitis is the most common bacterial infection of the oropharynx caused by Streptococcus pyogenes. Streptococcus pyogenes are gram-positive cocci that grow in chains and they display beta hemolysis when growing on blood agar plates. They belong to group A in the Lancefield classification system for beta-hemolytic Streptococcus, so they are called group A streptococci. 5 The Centor clinical criteria for the diagnosis of strep pharyngitis are sudden onset of fevers greater than 101 F, pharyngeal erythema with exudate, and tender anterior cervical adenopathy. Cough, rhinorrhea, and hoarseness are usually absent on bacterial pharyngitis. Bacterial caused strep pharyngitis is important because it can lead to the acute and long term postinfectious disease such as rheumatic fever or poststreptococcal glomerulonephritis if untreated. This presentation help practitioner to differentiate the diagnosis of bacterial pharyngitis with current clinical practice guideline so that the best evidence-based treatment can be offered to the patient. 6 The clinical practice guidelines for the group A streptococcal pharyngitis that we are discussing in this presentation was originally created in 2002 by the Infectious Diseases Society of America. The official title of the CPG is “Clinical practice guidelines for the diagnosis and management of group A streptococcal pharyngitis.” There has been subsequent update, which is the current one that we are using for this presentation, and it was done in 2012 and revisions were made in 2014. 7 The clinical diagnosis of strep pharyngitis can be difficult because patients not always come in with classic signs and symptoms; presenting symptoms vary with the age of the patient. These recommendations are all based on evidenced-based practice and are very thoroughly detail. 8 The specific recommendations on the management of this common disorder among adult and pediatric patients. The key points rating in the development of CPG guidelines include a systematic weighting of the strength of recommendation (strong, weak) and quality of evidence (high, moderate, low, very low) using GRADE (Grading of Recommendations Assessment, Development, and Evaluation system) 9 first recommendation: how the diagnosis of strep pharyngitis should be established? To diagnosis the patient looks for signs and symptoms of strep pharyngitis or throat infection. Unless patient have obvious viral s/s like rhinorrhea, cough, oral ulcers, and hoarseness, the clinical characteristics alone are hard to differentiate between bacterial and viral pharyngitis. There are two common tests used in making a diagnosis. Swabbing the throat and testing by Rapid antigen detection test should be tested. In adults, the culture is unnecessary; either the result is positive or negative. However, a throat culture may be done to confirm a diagnosis even if negative rapid tests in children and adolescents. Anti-streptococcal antibody titers may detect if patient had the Strep Pharyngitis in the past, but are not recommended in the routine diagnosis for current episode. 10 2nd recommendation: So, who should be testing for Group A Strep pharyngitis? The clinical diagnosis of strep pharyngitis is normally difficult. Because patients don't always present with classic signs and symptoms. If patient shows strong suggest s/s of the viral pharyngitis, a culture or rapid testing is not recommended. Routinely throat culture or rapid testing is not recommended for follow-up posttreatment or empiric treatment of asymptomatic household contacts of patients. The diagnostic test is not recommended for children under 3 years old because an incidence of Group A Strep infection is uncommon in children < 3 years old. However, testing may be needed if the patient has an older sibling with Strep infection. 11 Although an antibiotic is not indicated for viral pharyngitis. Antibiotic treatment is recommended for patients with confirmed Group A Strep pharyngitis. Once strep pharyngitis is confirmed, a proper antibiotic and dosages are recommended to cure and eliminate the organism. Drug of choice is Penicillin or amoxicillin if not contraindicated. 12 However, an individual is allergic to penicillin, First generation of cephalosporin, clindamycin, clarithromycin, or azithromycin are recommended. The recommended dose or dosage for Azithromycin has been revised in 2014. It is important to educate patients that the antibiotics courses should be finished to kill the infection completely and prevent relapse to the organism. 13 Adjunctive to a proper antibiotic, ibuprofen or acetaminophen may be used for relieving the pain or symptoms and reduce fever. Although aspirin can help reduce pain in adult, it is not recommended for children due to the risk of Reye syndrome which is rare syndrome that causes swelling in the liver and brain. The corticosteroid is not recommended due to the difficulty to compare the level of the result of effectiveness. Topical agents such as rinses, spray, and topical anesthetics may be given for temporary symptomatic relief. Lozenges may be effective in adults, but not recommended for young children due to a choking problem. 14 What if the patient has frequent recurrent episodes of Strep pharyngitis? Streptococcal carriers appear to be at little risk for developing rheumatic fever. In general, chronic carriers are not considered to be significant in the spread of Group A Streptococcus to others. Asymptomatic carriers do not need to be identified or treated except in high risk surroundings such as family history with rheumatic fever or post streptococcal glomerulonephritis. In the past, tonsillectomy was provided. However, with current clinical guideline, tonsillectomy is not recommended just to reduce the recurrent of Strep pharyngitis. 15 A 70-year-old female came to the clinic complain of sore throat, cough and loss of voice. Onset of symptoms started around 2 weeks ago. There was history of fever, sore throat, pain when swallow. On examination, she appeared tired, sob with exertion (moving chair to the exam table), bilateral upper lobes wheezing, leg swelling, the temperature was 98.1, posterior oropharynx erythematous without exudates, and the tonsils were not enlarged. With further investigation, patient reported coughing with plenty of phlegm, runny nose and diarrhea. She self-medicated with Mucinex, Robitussin, cough drop, Tylenol, and leftover Keflex for the last 10 days. Although the patient has the history of fever, sore throat, odynophagia, and tonsillopharyngeal erythematous, a diagnostic rapid test was not performed for couple of reasons. Onset of symptoms was already past 2 weeks ago, most cases are self-limiting, current clinical feature such as no fever, the presence of cough, and diarrhea strongly suggest a viral. In addition, patient had self-medicated with Keflex for last 10 days. Diagnosis with URI. Symptomatic treatments are provided to reduce the symptoms such as sore throat, cough and sob; Tylenol instead of NSAID due to kidney function. Patient has provided with take home inhaler steroid due to sob, and diabetic. Provided education on do not self-medication with antibiotic may develop the antibiotic resistance. Sore throat is one of the most common symptoms experienced by people at least one time or another and reason for visit in primary care. This CPG provides clear guidelines for diagnosis, treatment, and re-evaluation. It can useful in primary care to assist in making decisions, avoid misdiagnosis, proper treatment can be offered to the patient and to reduce inappropriate use of antibiotics in the treatment. 16 In conclusion, an accurate diagnosis and diagnostic testing is important that the practitioner to distinguish bacterial from viral pharyngitis so that the best evidence-based treatment can be offered to the patient. Once Group A Streptococcal pharyngitis is confirmed, it should be treated with penicillin unless allergic to penicillin. The main goals of treatment for Strep pharyngitis include help reducing the duration and severity of symptoms, preventing acute and delayed complications, and preventing the spread of infection to others. An adjunctive therapy may be offered Educate patients is very important part of treatment that patient need to finish the prescribed antibiotics. Lastly, handwashing regularly and avoid sharing personal stuffs such as utensils, water bottles, and toothbrushes to prevent infection. The diagnostic test is provided when it is indicated, not because it is available. Same goes to treating patients with antibiotic when is indicated. Using antibiotic when not indicated, it will cause unnecessary healthcare costs and expose patients to the risk of developing antibiotic resistance without any benefit. Thank you for watching. Publication & Applicability in Primary Care The student 30: 1) Identifies the author, organization or group that developed the CPG, 2) Student denotes the year of the original guideline publication, 3) Student identifies any subsequent revisions (student’s reference should be the most recent version), 4) Student discusses the applicability for use of this CPG in the primary care setting. Key Action Statements & Body of Evidence The student 45: 1)Provides each of the CPG’s “Key Action” or “Guideline Statements” up to a maximum of 5 relevant recommendations, 2) Provides the body of evidence strength for each, and 3) If the statement has applicability to other groups, only discuss the relevant primary care ones. Application in Clinical 45: 1) Using an example of a patient from their clinical rotation with the same condition, 2) Student discusses how the diagnosis and treatment of their patient compared to the recommendations given in the guidelines, and 3). Specific examples of what was done well or what could have been done better is noted. Presentation 15: 1) The student used PowerPoint and Voicethread or Kaltura and presentation was professional in quality, 2) Slides were well organized and aesthetically pleasing, 3) Student’s narration was understandable and well-paced, 4) References were noted, 5) Presentation was under 15min in length. (5 critical elements).