Systematic review and meta-analysis of the accuracy of McIsaac and Centor score in patients presenting to secondary care with pharyngitis

Do Hospitalized Adult Patients with Acute Pharyngotonsillitis Need Empiric Antibiotics? The Impact on Antimicrobial Stewardship

Acute pharyngotonsillitis is a common reason to visit primary care providers. Group A Streptococcal (GAS) pharyngitis is the most common bacterial infection which needs antibiotic treatment. GAS accounts for only 10-15% of adult acute pharyngitis cases. The overuse of antibiotics for viral pharyngotonsillitis is common and may lead to inappropriate antimicrobial stewardship and the emergence of bacterial resistance. However, the etiology of acute pharyngotonsillitis for hospitalized adult patients is rarely studied. So, we reported the 10-year surveillance data of hospitalized adult patients with acute pharyngotonsillitis in a regional hospital in Taiwan. Every consecutive adult patient admitted with acute pharyngotonsillitis in 2011-2021 was recruited for a complete etiology study. The etiology of acute pharyngotonsillitis was identified in 117 patients. Overall, 42 herpes simplex virus cases, 26 adenovirus cases, 16 acute human immunodeficiency virus cases, 12 influenza cases, three parainfluenza cases, six Epstein-Barr virus cases, one cytomegalovirus case, four enterovirus cases, one varicella-zoster virus case, four Mycoplasma pneumoniae cases, one Chlamydophila pneumoniae case, and only one GAS case were identified. The average of the points for the Modified Centor Criteria was 1.38 (55% of patients with 0-1 points and 45% with 2-3 points). However, 88.9%of patients received antibiotics at the emergency department, and 76.9%also received antibiotics while hospitalized. Only a few patients required antibiotic treatment, while the majority of patients with viral illness needed only symptomatic treatment. However, distinguishing viral etiology from GAS pharyngitis is challenging even in the presence of tonsil exudates, high C-reactive protein, and leukocytosis. A diagnostic algorithm and the application of the Modified Centor Criteria should be considered for hospitalized adults with acute pharyngotonsillitis to improve antimicrobial stewardship.

Open, Randomised, Controlled Study to Evaluate the Role of a Dietary Supplement Containing Pelargonium sidoides Extract, Honey, Propolis, and Zinc as Adjuvant Treatment in Children with Acute Tonsillopharyngitis

BACKGROUND/OBJECTIVES

A common reason for a pediatrician's visit is acute tonsillopharyngitis (ATR), which is usually caused by viruses. A dietary supplement comprising Pelargonium sidoides extract, honey, propolis, and zinc was proposed as an effective adjuvant for the management of respiratory tract infections. The study aimed to determine the efficacy of this dietary supplement in conjunction with standard of care (SoC) compared to SoC alone, in a pediatric population affected by ATR.

METHODS

This open randomized study (registered on ClinicalTrials.gov: NCT04899401) involved three Romanian sites specialized in pediatric care. The primary endpoints were changes in Tonsillitis Severity Score and the number of patients failing to respond (evaluating the use of ibuprofen or high-dose paracetamol as a rescue medication). One hundred and thirty children, distributed into two groups, were enrolled and treated for six days.

RESULTS

The results showed an overall better performance in terms of efficacy of dietary supplement + SoC, compared to SoC alone, with lower total Tonsillitis Severity Score ratings on day 6 (p = 0.002) and lower sub-scores related to erythema and throat pain on day 6. No adverse events were reported. Investigators found compliance to be optimal.

CONCLUSIONS

The administration of the dietary supplement + SoC in pediatric patients with ATR was found to be safe and superior to the administration of SoC alone in terms of efficacy. The results confirmed that the tested dietary supplement is an optimum effective adjuvant in the treatment of respiratory tract infections and is suitable for the daily clinical practice of pediatricians.

Centor scores associated poorly with rapid antigen test findings in children with sore throat

The Finnish Current Care Guideline recommends rapid antigen tests as the primary diagnostic tool for both adults and children with Centor score ≥ 3. We aimed to analyze the association of Centor score and rapid antigen test positivity of group A streptococcal pharyngitis (GAS) in Finnish children. We performed a retrospective single-center study from July 2019 to June 2022. We included all children aged 0-15 years based on ICD-10 diagnostic codes for acute pharyngitis. We manually extracted the data from the electronic healthcare records. We extracted the information on Centor score signs and symptoms, rapid antigen tests, throat cultures, and C-reactive protein (CRP) levels. Comparisons were made between different groups by calculating a difference of two proportions with 95% confidence intervals. A total of 464 children were included and rapid antigen tests were taken from 433 (93.3%). We did not detect any significant association between rapid antigen test positivity and Centor scores. Sensitivity of Centor score ≥ 3 for rapid antigen test positivity was 22.3 (95% confidence interval 17.3-27.9) and specificity 79.0% (72.4-84.8). Positive throat culture was found in 17.1% of the patients with negative rapid antigen test. Centor scores correlated positively with CRP levels, but elevated CRP did not predict positive antigen test results.

CONCLUSION

 The Centor score alone does not seem to be of any utility in guiding the diagnosis of suspected streptococcal pharyngitis. Microbiological testing remains necessary for accurate diagnosis and CRP should not be used to differentiate viral and bacterial pharyngitis cases.

WHAT IS KNOWN

• The Centor score is a clinical prediction model for differentiating Group A streptococcal (GAS) pharyngitis from viral pharyngitis. • Finnish Current Care Guideline recommends rapid antigen testing in patients with Centor score ≥ 3 for diagnosing GAS infections and antibiotics prescribed based on confirmed test results.

WHAT IS NEW

• The Centor score alone does not seem to have any use in guiding the diagnosis of suspected streptococcal pharyngitis in children. • Microbiological testing remains necessary for accurate diagnosis in patients with sore throat.

[Clinical diagnosis of group A streptococcal pharyngitis and progress in the application of scoring systems]

Pharyngitis can be caused by various pathogens, including viruses and bacteria. Group A streptococcus (GAS) is the most common bacterial cause of pharyngitis. However, distinguishing GAS pharyngitis from other types of upper respiratory tract infections is challenging in clinical settings. This often leads to empirical treatments and, consequently, the overuse of antimicrobial drugs. With the advancement of antimicrobial drug management and healthcare payment reform initiatives in China, reducing unnecessary testing and prescriptions of antimicrobial drugs is imperative. To promote standardized diagnosis and treatment of GAS pharyngitis, this article reviews various international guidelines on the clinical diagnosis and differential diagnosis of GAS pharyngitis, particularly focusing on clinical scoring systems guiding laboratory testing and antimicrobial treatment decisions for GAS pharyngitis and their application recommendations, providing a reference for domestic researchers and clinical practitioners.

Symptoms predictive of Fusobacterium necrophorum pharyngotonsillitis - an observational study of cases presenting to hospitals in Southern Sweden

OBJECTIVES

Fusobacterium necrophorum is a common cause of pharyngotonsillitis. However, no guidelines exist on when to diagnose or treat it. We aimed to investigate associations between clinical criteria and F. necrophorum-positivity in pharyngotonsillitis and assess the predictive potential of a simple scoring system.

METHODS

Pharyngotonsillitis patients who were tested for F. necrophorum (PCR) and presented to hospitals in the Skåne Region, Sweden, between 2013-2020 were eligible. Data were retrieved from electronic chart reviews and registries. By logistic regression we investigated associations between F. necrophorum-positivity and pre-specified criteria: age 13-30 years, symptom duration ≤ 3 days, absence of viral symptoms (e.g. cough, coryza), fever, tonsillar swelling/exudate, lymphadenopathy and CRP ≥ 50 mg/L. In secondary analyses, associated variables were weighted by strength of association into a score and its predictive accuracy of F. necrophorum was assessed.

RESULTS

Among 561 cases included, 184 (33%) had F. necrophorum, which was associated with the following criteria: age 13-30, symptom duration ≤ 3 days, absence of viral symptoms, tonsillar swelling/exudate and CRP ≥ 50 mg/L. Age 13-30 had the strongest association (OR5.7 95%CI 3.7-8.8). After weighting, these five variables had a sensitivity and specificity of 68% and 71% respectively to predict F. necrophorum-positivity at the proposed cut-off.

CONCLUSION

Our results suggest that F. necrophorum cases presenting to hospitals might be better distinguished from other pharyngotonsillitis cases by a simple scoring system presented, with age 13-30 being the strongest predictor for F. necrophorum. Prospective studies, involving primary care settings, are needed to evaluate generalisability of findings beyond cases presenting to hospitals.

Group A Streptococcal Infections in Pediatric Age: Updates about a Re-Emerging Pathogen

Group A Streptococcus (GAS) presents a significant global health burden due to its diverse clinical manifestations ranging from mild infections to life-threatening invasive diseases. While historically stable, the incidence of GAS infections declined during the COVID-19 pandemic but resurged following the relaxation of preventive measures. Despite general responsiveness to β-lactam antibiotics, there remains an urgent need for a GAS vaccine due to its substantial global disease burden, particularly in low-resource settings. Vaccine development faces numerous challenges, including the extensive strain diversity, the lack of suitable animal models for testing, potential autoimmune complications, and the need for global distribution, while addressing socioeconomic disparities in vaccine access. Several vaccine candidates are in various stages of development, offering hope for effective prevention strategies in the future.