20112ed8-b65e-4282-a009-a0e323868ca9.pdf
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The document discusses acute pharyngitis (sore throat) in adolescents and adults. It notes that viral infections are the predominant cause of pharyngitis overall. Clinical prediction scores can help determine which patients should undergo testing for Group A Streptococcal (GAS) pharyngitis. For patients diagnosed with GAS pharyngitis, penicillin is the first-line antibiotic therapy for non-allergic patients. The document stresses educating patients that most sore throats are viral and do not require antibiotics, as patient expectations can drive inappropriate antibiotic prescribing.
![Acute pharyngitis
5
• Common target for
antimicrobial stewardship
– Majority due viral
infections
– Broad-spectrum
antimicrobials used
inappropriately
Lord Akryl (http://cancer.gov) [Public domain], via Wikimedia Commons](https://image.slidesharecdn.com/20112ed8-b65e-4282-a009-a0e323868ca9-240124165226-9e2afca9/85/20112ed8-b65e-4282-a009-a0e323868ca9-pdf-6-320.jpg)
![36
Group A streptococcal causes:
– 20 – 30% pharyngitis in
children
– 5 – 15 % of pharyngitis in
adults
Pharyngitis in adults
By Lord Akryl (http://cancer.gov) [Public domain], via Wikimedia Commons](https://image.slidesharecdn.com/20112ed8-b65e-4282-a009-a0e323868ca9-240124165226-9e2afca9/85/20112ed8-b65e-4282-a009-a0e323868ca9-pdf-37-320.jpg)
20112ed8-b65e-4282-a009-a0e323868ca9.pdf
- 1. Acute pharyngitis in adolescents and adults
- 2. Course content Course roadmap Basic concepts Common infections 1
- 3. “We need ways to target all behaviours that contribute to the misuse of these fragile medicines.” Dr. Margaret Chan New York, USA April 18, 2016 2
- 4. Core competencies for antimicrobial prescribing C1: Understands the patient and the patient’s clinical needs C2: Understands treatment options and how they support the patient’s clinical needs C3: Works in partnership with the patient and other healthcare professionals to develop and implement a treatment plan C4: Communicates the treatment plan and its rationale clearly to the patient and other health professionals C5: Monitors and reviews the patient’s response to treatment 3 Core Competencies
- 5. Objectives • Understand the epidemiology of infectious etiologies of acute pharyngitis • Use clinical prediction scores and microbiologic tests to identify those that may benefit from antimicrobial therapy. • Recognize communication tools that can be used to educate patients about their diagnoses and the appropriate use of antimicrobials 4
- 6. Acute pharyngitis 5 • Common target for antimicrobial stewardship – Majority due viral infections – Broad-spectrum antimicrobials used inappropriately Lord Akryl (http://cancer.gov) [Public domain], via Wikimedia Commons
- 7. Harm associated with antimicrobials • Adverse events • Clostridium difficile colitis • Cost • Emergence of antimicrobial resistance 6
- 8. 7 Case #1 Sore throat Case #2 Sore throat
- 9. Case 1 Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 8
- 10. 14 year-old male with: 2 day history of sore throat & fever no rhinorrhea or cough temperature 38.5o C no acute distress erythematous posterior pharynx with exudate 9
- 11. Streptococcus pyogenes 10 • Group A Streptococcus • Most common bacterial etiology of pharyngitis • More common in children • Estimated to cause 5-15% of cases of sore throat in adults U.S. Centers for Disease Control and Prevention – Medical Illustrator
- 12. Acute pharyngitis 11 Viral pathogens are the predominant cause of pharyngitis overall!
- 13. 12 Appropriate Antibiotics for Group A Streptococcus pharyngitis Inappropriate Antibiotics for Viral pharyngitis
- 14. Modified Centor Score 13 Criteria Point Temperature >38C 1 No cough 1 Tender anterior cervical adenopathy 1 Tonsillar swelling or exudate 1 Age 3 -14 years 1 Age 15 – 44 years 0 Age > 44 years -1 Total Score Risk of group A streptococcal pharyngitis ≥ 4 38 – 63% 3 27 – 28% 2 10 – 12% 1 4 – 6% 0 2 – 3%
- 15. Diagnostic challenges • Validated prediction scores have limitations. • May help determine who does not need testing • A positive microbiologic test may represent carriage 14 WHO/A. Kristensen
- 16. Assess for signs of viral upper respiratory tract infection • Conjunctivitis • Coryza • Cough • Diarrhea • Hoarseness • Viral exanthema • Oral ulcers 15 CDC/Brian Judd
- 17. Rapid antigen testing 16 A rapid antigen diagnostic tests that is negative for Group A Streptococcal pharyngitis provides reassurance that a antibiotics are unlikely to be needed. WHO/A. Kristensen
- 18. 17 Remain vigilant: • Life-threatening causes of sore throat • Other treatable causes (e.g. gonococcal pharyngitis)
- 19. 14 year-old male with: 2 day history of sore throat & fever no rhinorrhea or cough temperature 38o C no acute distress erythematous posterior pharynx with exudate 18
- 20. An informed choice Severity Source Drug resistance Patient factors Cultures Core Competencies 1 & 2 Optimal antibiotics 19
- 21. Severity Source Drug resistance Patient factors Cultures Not severe How severe is the patient’s condition? 20
- 22. What is the likely source & pathogens? Severity Source Drug resistance Patient factors Cultures • Group A Streptococcus pharyngitis? • No signs of viral URI 21
- 23. What is the likely source & pathogens? Severity Source Drug resistance Patient factors Cultures 22 Criteria Point Temperature >38C 1 No cough 1 Tender anterior cervical adenopathy - Tonsillar swelling or exudate 1 Age 3 -14 years 1 Age 15 – 44 years - Age > 44 years - TOTAL 4 Total Score Risk of group A streptococcal pharyngitis ≥ 4 38 – 63% 3 27 – 28% 2 10 – 12% 1 4 – 6% 0 2 – 3%
- 24. Severity Source Drug resistance Patient factors Cultures Unlikely. Group A streptococcus remains sensitive to penicillin How likely is resistance? 23
- 26. Severity Source Drug resistance Patient factors Cultures Rapid antigen testing Do I need cultures? 25
- 27. Severity Source Drug resistance Patient factors Cultures Rapid antigen testing = POSITIVE Do I need cultures? 26
- 28. Severity Source Drug resistance Patient factors Cultures Core Competencies 1 & 2 Penicillin 27
- 29. 55 year-old male with: 2 day history of sore throat & fever + rhinorrhea and mild cough temperature 38.2o C no acute distress erythematous posterior pharynx with exudate 28
- 30. Severity Source Drug resistance Patient factors Cultures Not severe How severe is the patient’s condition? 29
- 31. What is the likely source & pathogens? Severity Source Drug resistance Patient factors Cultures Viral upper respiratory tract infection most likely 30
- 32. What is the likely source & pathogens? Severity Source Drug resistance Patient factors Cultures 31 Criteria Point Temperature >38C 1 No cough - Tender anterior cervical adenopathy - Tonsillar swelling or exudate 1 Age 3 -14 years - Age 15 – 44 years - Age > 44 years -1 TOTAL 1 Total Score Risk of group A streptococcal pharyngitis ≥ 4 38 – 63% 3 27 – 28% 2 10 – 12% 1 4 – 6% 0 2 – 3%
- 33. Severity Source Drug resistance Patient factors Cultures No Do I need cultures? 32 Guidelines recommend against microbiologic testing in patients with a low likelihood of Group A Streptococcus pharyngitis
- 34. Severity Source Drug resistance Patient factors Cultures Core Competencies 1 & 2 No antibiotics 33
- 36. Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 35 • Give specific diagnosis • Provide reassurance • Symptomatic therapy • Advise against acquiring antibiotics by other means • Offer follow-up visit (safety net)
- 37. 36 Group A streptococcal causes: – 20 – 30% pharyngitis in children – 5 – 15 % of pharyngitis in adults Pharyngitis in adults By Lord Akryl (http://cancer.gov) [Public domain], via Wikimedia Commons
- 38. 37 Important to educate patients that the majority of patients with sore throat do well without antibiotics. Patient expectations may drive inappropriate antibiotic use
- 39. 38 Consider asking patients directly if they expect to receive antibiotics during this encounter and why to facilitate communication. Clinicians may overestimate their patients desire for antibiotics
- 40. Review: Pharyngitis in Adults & Adolescents Drug Dose Duration Route prescription ............. ............. ............. 39
- 41. Review: Pharyngitis in Adults & Adolescents Drug Dose Duration Route prescription ............. ............. ............. Acute pharyngitis in adults is most commonly caused by a viral infection.
- 42. Review: Pharyngitis in Adults & Adolescents Clinical prediction scores can be used to determine which patients should undergo microbiologic testing for Group A Streptococcal pharyngitis. Drug Dose Duration Route prescription ............. ............. .............
- 43. Review: Pharyngitis in Adults & Adolescents Drug Dose Duration Route prescription ............. ............. ............. Penicillin is first-line therapy in non-allergic patients diagnosed with streptococcal pharyngitis.
- 44. Review: Pharyngitis in Adults & Adolescents Drug Dose Duration Route prescription ............. ............. ............. Directly ask regarding your patient’s expectations for antibiotics to facilitate communication.
- 45. Quiz time! Please click “Next” to proceed.