SAN FRANCISCO – Most group A streptococcus tests performed in pediatric outpatients at a major children’s hospital were indicated based on current guidelines, but a significantly higher than expected proportion of children were treated with antibiotics, according to findings from a chart review.
Furthermore, 11.1% of the antibiotics prescribed to those patients were nonrecommended agents, Dr. Thea Brennan-Krohn reported in a poster at an annual scientific meeting on infectious diseases.
Included in the study were 234 patients, aged 3-18 years, who had a streptococcal rapid antigen detection test and/or a throat culture performed between Aug. 1, 2011, and July 31, 2013. The tests were indicated – based on a McIsaac score of 2 or greater as recommended by Infectious Diseases Society of America (IDSA) guidelines – in 95.7% of cases. If the patients had been managed according to guidelines, 8.1% would have received antibiotics, but 11.5% actually received antibiotics, reported Dr. Brennan-Krohn of Boston Children’s Hospital.
Children whose charts were reviewed as part of this study presented with pharyngitis to a clinic or emergency department at the hospital. According to the IDSA guidelines, testing is not recommended for those with acute pharyngitis with features that strongly suggest viral etiology, such as cough, rhinorrhea, hoarseness, or oral ulcers. Recommended antimicrobial agents in those who have group A streptococcus include penicillin V, amoxicillin, or intramuscular benzathine penicillin G in those without penicillin allergy, and cephalexin/cefadroxil, clindamycin, or azithromycin/clarithromycin in those who do have penicillin allergy.
Prior studies have demonstrated that guidelines are not consistently followed in adults. The current study is among the first to use individual patient data to assess guideline adherence in the pediatric population. The findings suggest that "there remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings," Dr. Brennan-Krohn said.
Plans are underway to repeat the study in a large community-based practice setting to evaluate management of pharyngitis beyond the academic medical center setting, she noted at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
"Further investigation may help to clarify why pediatric providers appear to adhere more closely to pharyngitis management guidelines than adult providers," she concluded.
This study was supported by the Fred Lovejoy Housestaff Research and Education fund.