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Diagnosis and Treatment of Acute Pharyngitis/Tonsillitis: a Preliminary Observational Study in General Medicine

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Diagnosis and Treatment of Acute Pharyngitis/Tonsillitis: a Preliminary Observational Study in General Medicine Eur opean Rev iew for Med ical and Pharmacol ogical Sci ences 2016; 20: 4950-4954 Diagnosis and treatment of acute pharyngitis/tonsillitis: a preliminary observational study in General Medicine F. DI MUZIO, M. BARUCCO, F. GUERRIERO Azienda Sanitaria Locale Roma 4, Rome, Italy Abstract. – OBJECTIVE : According to re - pharmaceutical expenditure, without neglecting cent observations, the insufficiently targeted the more important and correct application of use of antibiotics is creating increasingly resis - the Guidelines with performing of a clinically val - tant bacterial strains. In this context, it seems idated test that carries advantages for reducing increasingly clear the need to resort to extreme the use of unnecessary and potentially harmful and prudent rationalization of antibiotic thera - antibiotics and the consequent lower prevalence py, especially by the physicians working in pri - and incidence of antibiotic-resistant bacterial mary care units. In clinical practice, actually the strains. general practitioner often treats multiple dis - eases without having the proper equipment. In Key Words: particular, the use of a dedicated, easy to use Acute pharyngitis, Tonsillitis, Strep throat, Beta-he - diagnostic test would be one more weapon for molytic streptococcus Group A (GABHS), Rapid anti - the correct diagnosis and treatment of acute gen detection test, Appropriateness use of antibiotics, pharyngo-tonsillitis. The disease is a condition Cost savings in pharmaceutical spending. frequently encountered in clinical practice but its optimal management remains a controver - sial topic. In this context, the observational study is intended to demonstrate the useful - ness of the rapid test (RAD: Rapid antigen de - Introduction tection) against group A beta-hemolytic strep - tococcus (GABHS) in everyday clinical practice Physical examination of the oropharynx is the to identify individuals with acute streptococcal pharyngo-tonsillitis needing antibiotic therapy best method for making a diagnosis of strep and to pursue the following objectives: (1) Get - throat but rarely provides sufficient evidence to ting the answer to an unmet medical need; (2) secure its etiology. Usually , there is a widespread Promoting the appropriateness of the use of hyperemia of the mucosa of the tonsils, more or antibiotics; (3) Provide a means of containment less extended to the pharynx, which may be asso - in pharmaceutical spending. ciated with other signs such as tonsillar exudate, PATIENTS AND METHODS: 50 patients pre - senting sore throat associated with erythema petechiae on the soft palate or, more rarely, sores . and/or pharyngeal tonsillar exudate with or with - The tonsillar exudates – whitish or frankly pu - out scarlatiniform rash, fever and malaise had rulent – is often considered the only element re - been subjected to perform a rapid test (RAD: lated to the etiology of GABHS (Beta Hemolytic Rapid antigen detection) for the search of the Streptococcus Group A ). Many viruses, in partic - beta-hemolytic Streptococcus Group A (GABHS). ular adenovirus, and Epstein-Barr virus, may de - Pharyngeal-tonsillar swabs were tested using termine a comparative exudative tonsillitis, if not Immunospark (relative sensitivity 97.6%, relative specificity 97.5%) according to manufacturer's even more accentuated than what would be ex - instructions (runtime/reading response < 10 pected to be a typical GABHS. Petechiae are of - min). ten associated with a streptococcal etiology, RESULTS: Of the 50 tests, 45 provided a nega - while ulcerative lesions are most often associated tive response while 5 were positive for the with viral forms. search of the beta-hemolytic Streptococcus Some epidemiological data and symptoms as - group A. No test result has been invalid. sociated with local signs of strep throat may con - CONCLUSIONS: Based on the results ob - 1,2 tained, only patients with a positive rapid test tribute to an etiologic diagnosis . Typical indica - were subjected to targeted antibiotic therapy. tions of the onset of the disease from GABHS This has resulted in a significant cost savings in have been: its acute onset, the absence of other 4950 Corresponding Author: Flavio Di Muzio, MD; e-mail: [email protected] Diagnosis and treatment of acute pharyngitis/tonsillitis acute respiratory tract illnesses in the patients’ streptococcal pharyngitis because the presence of households, the onset in late winter or early these antibodies reflects past infections and not spring, the age of 3-4 years, the high fever, the ongoing infections 10 . sore throat, intense headache and sore laterocer - Once diagnosed, patients with streptococcal vical lymphadenopathy . pharyngo-tonsillitis should be treated with an The viral forms, however, were thought to be appropriate antibiotic, in the correct dosage for characterized by more modest acute systemic the duration necessary for the eradication of symptoms, with less febrile temperature, but GABHS from the pharynx. Baseline antibiotics concomitant involvement of the upper airways, for not allergic patients are penicillins, in partic - the presence of family members with a similar ular amoxicillin. Treatment of streptococcal disease, more gradual onset, usually in the sum - pharyngo-tonsillitis in patients allergic to peni - mer, and elective involvement of the very first cillin should include (except cross-reactions) a years of life. first-generation cephalosporin/second genera - The symptoms of streptococcal pharyngo-ton - tion for 10 days (5-6 days for a third-generation sillitis and non-streptococcal varieties overlap cephalosporin in case of dubious compliance to and merge so widely that an accurate diagnosis 10-days therapy) or clarithromycin for 10 days made only on the basis of clinical signs is virtual - or azithromycin for 5 days: recommended for ly impossible, although some have been pro - patients with demonstrated IgE-mediated aller - 3 posed as clinical scores, such as the Mc Isaac . gy to β-lactam because of reporting macrolides Considering that the acute pharyngo-tonsillitis resistant bacterial strains 11-15 . is one of the diseases that pediatricians and gener - al practitioners most frequently encounter (15 mil - lion visits per year in the US alone), only a rela - Patients and Methods tively small percentage of patients (20%-30% of pediatric patients, even less in adults) are actually Patient suffering from pharyngo-tonsillitis by GABHS. From November 2014 to April 2015, 50 adult With the exception of other rare bacterial in - patients (mean age 27.48 years) with signs and fections of the pharynx (caused by Corynebac - symptoms of acute pharyngo-tonsillitis were ob - terium diphtheriae and Neisseria gonorrhoeae ), served, in a study of general medicine. These pa - antibiotic therapy is unnecessary for the acute tients, who in the absence of diagnostic tests pharyngo-tonsillitis caused by other microorgan - (rapid test for GABHS), and even applying EBM isms than GABHS even more so because most (Evidence Based Medicine) , may be treated with cases are caused by viruses and in particular ade - oral antibiotics (penicillin/cephalosporin or novirus, influenza and parainfluenza viruses. It is macrolide if allergic). Informed consent was extremely important to make the diagnosis accu - signed and reported in medical records. rately to avoid unnecessary and potentially harm - Inclusion criteria (Figures 1 and 2): Major: ful antibiotic prescriptions 4-6 . sore throat associated with erythema and/or pha - At present , it is recommended to obtain a pha - ryngeal tonsillar swab for rapid antigen testing (RAD: Rapid antigen detection) in children or adolescents with a history, signs and/or symp - toms of suspected infection by GABHS. If RAD test response is negative in subjects where there is strong evidence or suspicion of infection, a bacterial culture should be performed. In the case of a positive RAD test response, the bacterial culture is not necessary for the high reliability and specificity of the tests 7-9 . Bacterial culture is not necessary for the rou - tine diagnosis of an acute pharyngitis by GABHS in consideration of the correlation of the rapid test with culture. The dosage of the anti strepto - coccus antibodies ASO (Anti-streptolysin O) is not recommended in the routine diagnosis of Figure 1. 4951 F. Di Muzio, M. Barucco, F. Guerriero Total amount: €100.00 ( figurative total cost of 50 kits ) + €65.56 ( total cost of antibiotic therapy for positive RAD patients ) = €165.56 (Figure 4). If all 50 patients were treated equally, based only on clinical evaluation (without the adminis - tering of the rapid test), with amoxicillin (not considering any allergies to penicillin and/or dif - ferent treatment choices) the cost of antibiotics would be: €6.54 (two pill boxes/person) x 50 = €327.00 ( Figure 4). The cost savings from only the positive pa - tients treated correctly (rapid test + antibiotic ad hoc) and all 50 patients who were treated empiri - cally based only on clinical data (only antibiotic without rapid test) would be as follows : €100.00 (figurative total cost 50 kit) + €65.56 ( total cost Figure 2. of antibiotic therapy for positive RAD patients ) – €327.00 (pharmaceutical expenditure of all 50 patients treated without distinction) = –€161.44 ryngeal/tonsillar exudate with or without scarla - equal to 49 .4% ( Figure 4). tiniform rash. Minor: fever, general malaise. Ma - If we consider the use of the currently more jor criteria must always be present. expensive oral antibiotic
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