Empirical validation of guidelines for the management of pharyngitis in children and adults
Empirical validation of guidelines for the management of pharyngitis in children and adults
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DOI：
10.1001/jama.291.13.1587
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发表时间：
2004-04-07
影响因子：
120.7
通讯作者：
Low, DE
中科院分区：
文献类型：
--
作者：
McIsaac, WJ;Kellner, JD;Low, DE
背景最近的咽炎治疗指南在经验性抗生素治疗和实验室确认A组链球菌（GAS）的必要性方面有不同的建议。目的评估指南建议和替代方法对儿童和成人GAS咽炎的识别和治疗的影响。和参与者从1999年9月到2002年8月，在阿尔伯塔的卡尔加里的一家家庭医学诊所，对787名患有急性咽喉痛的3 - 69岁儿童和成人进行了咽喉培养和快速抗原检测。2项准则的建议（美国传染病学会和美国医师学会-美国内科学会/美国家庭医生学会/美国疾病控制和预防中心）与单独的快速检测进行了比较，（即，改良的Centor评分），主要结果测量每种治疗策略的敏感性和特异性，结果在儿童中，链球菌感染的敏感性从快速检测的85.8%（133/155; 95%可信区间[CI]，79.3%-90.0%）到全部培养的100%。在成人中，灵敏度范围为76.7%（56/73; 95% CI，65.4%-85.8%）（快速检测，无阴性结果培养确认）至100%（全部培养）。在儿童中，特异性范围为90.3%（270/299; 95% CI，86.4%-93.4%）（使用改良Centor评分和咽喉培养）至100%（全部培养）。在成人中，根据修改后的Centor评分3或4，经验治疗的特异性范围为43.8%（114/260; 95%CI，37.7%-50.1%），而所有培养的特异性范围为100%。快速检测的抗生素处方总数最低（24.7% [194/787]; 95% CI，21.7%-27.8%），高危成人经验性治疗组最高（45.7% [360/787]; 95% CI，42.2%-49.3%），由于成人中不必要处方的比例较高（43.8% [146/333]; 95%置信区间，38.4%-49.4%）结论指南建议选择性使用咽部培养，但仅根据快速试验或咽部培养阳性结果进行抗生素治疗，可减少咽炎治疗中不必要的抗生素使用。然而，对Centor评分为3或4的成人进行经验性治疗与不必要的抗生素使用率高相关。在儿童中，结合咽培养或咽培养确认阴性快速抗原检测结果的策略具有高度敏感性和特异性。所有成人或根据临床预测规则选择的人的咽培养具有最高的敏感性和特异性。
Context Recent guidelines for management of pharyngitis vary in their recommendations concerning empirical antibiotic treatment and the need for laboratory confirmation of group A streptococcus (GAS).Objective To assess the impact of guideline recommendations and alternative approaches on identification and treatment of GAS pharyngitis in children and adults.Design, Setting, and Participants Throat cultures and rapid antigen tests were performed on 787 children and adults aged 3 to 69 years with acute sore throat attending a family medicine clinic in Calgary, Alberta, from September 1999 to August 2002. Recommendations from 2 guidelines (those of the Infectious Diseases Society of America and of the American College of Physicians-American Society of Internal Medicine/American Academy of Family Physicians/US Centers for Disease Control and Prevention) were compared with rapid testing alone, a clinical prediction rule (ie, the modified Centor score), and a criterion standard of treatment for positive throat culture results only.Main Outcome Measures Sensitivity and specificity of each strategy for identifying GAS pharyngitis, total antibiotics recommended, and unnecessary antibiotic prescriptions.Results In children, sensitivity for streptococcal infection ranged from 85.8% (133/155; 95% confidence interval [CI], 79.3%-90.0%) for rapid testing to 100% for culturing all. In adults, sensitivity ranged from 76.7% (56/73; 95% CI, 65.4%-85.8%) for rapid testing without culture confirmation of negative results to 100% for culturing all. In children, specificity ranged from 90.3% (270/299; 95% CI, 86.4%-93.4%) for use of modified Centor score and throat culture to 100% for culturing all. In adults, specificity ranged from 43.8% (114/260; 95% CI, 37.7%-50.1%) for empirical treatment based on a modified Centor score of 3 or 4 to 100% for culturing all. Total antibiotic prescriptions were lowest with rapid testing (24.7% [194/787]; 95% CI, 21.7%-27.8%) and highest with empirical treatment of high-risk adults (45.7% [360/787]; 95% CI, 42.2%-49.3%), due to a high rate of unnecessary prescriptions in adults (43.8% [146/333]; 95% CI, 38.4%-49.4%).Conclusions Guideline recommendations for the selective use of throat cultures but antibiotic treatment based only on positive rapid test or throat culture results can reduce unnecessary use of antibiotics for treatment of pharyngitis. However, empirical treatment of adults having a Centor score of 3 or 4 is associated with a high rate of unnecessary antibiotic use. In children, strategies incorporating throat culture or throat culture confirmation of negative rapid antigen test results are highly sensitive and specific. Throat culture of all adults or those selected on the basis of a clinical prediction rule had the highest sensitivity and specificity.