Journal of General Internal Medicine

, Volume 28, Issue 6, pp 830–834 | Cite as

Management of Adults with Acute Streptococcal Pharyngitis: Minimal Value for Backup Strep Testing and Overuse of Antibiotics

Original Research

ABSTRACT

BACKGROUND

Rapid antigen detection tests (RADT) are commonly used to guide appropriate antibiotic treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis. In adults, there is controversy about the need for routine backup testing of negative RADT.

OBJECTIVE

Estimate the costs and benefits in adults of routine backup testing by DNA Gen-probe of negative RADT (Acceava).

DESIGN

Observational follow-up study.

PARTICIPANTS

All patients aged 18 years and older visiting a Cleveland Clinic generalist physician in 2009 and 2010 with a visit diagnosis of acute pharyngitis (ICD codes 462, 034.0).

MAIN MEASURES

The patients were identified using the Cleveland Clinic Epic Clarity database. We determined the proportion of false negative RADT, antibiotic prescription patterns and rate of serious suppurative complications within 30 days of the office visit.

KEY RESULTS

Of 25,130 patients with acute pharyngitis, 19 % had no testing and 81 % were tested. Of the 15,555 patients that had a negative RADT and follow-up DNA probe, 6 % had a positive DNA probe. Of the 953 patients who had a negative RADT and a positive DNA strep probe, 48 % received an antibiotic prescription at the time of the visit and 51 % received an antibiotic prescription after an average of 2.3 days. Only one patient with a negative RADT and no follow-up DNA probe developed a peritonsillar abscess. Overall, of the 15,555 DNA probes performed, management was altered in only 3 % of the patients at a total cost of $1,757,715. Fifty-six percent received an antibiotic while only 19.5 % had a confirmed strep throat diagnosis.

CONCLUSIONS

The false negative rate of Acceava RADT for the diagnosis of GABHS pharyngitis was 6 %. We question the benefit of routine DNA probe backup testing in adults because of its substantial cost, an average delay in antibiotic prescribing of over 2 days, and because suppurative complications are very uncommon. We found a high rate of inappropriate antibiotic prescribing.

KEY WORDS

acute pharyngitis strep throat testing rapid antigen detection tests RADT DNA probe 

REFERENCES

  1. 1.
    Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2000 summary. Adv Data. 2002;328:1–32.PubMedGoogle Scholar
  2. 2.
    Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. Natl Health Stat Report. 2008;8:1–29.PubMedGoogle Scholar
  3. 3.
    Bisno AL. Acute pharyngitis: etiology and diagnosis. Pediatrics. 1996;97:949–54.PubMedGoogle Scholar
  4. 4.
    Snow V, Mottur-Pilson C, Cooper RJ, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med. 2001;134:506.PubMedCrossRefGoogle Scholar
  5. 5.
    Linder JA. Evaluation and management of adult pharyngitis. Compr Ther. 2008;34(3–4):196–203.PubMedGoogle Scholar
  6. 6.
    Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH. Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Infectious Diseases Society of America. Clin Infect Dis. 1997;25(3):574–83. Review.PubMedCrossRefGoogle Scholar
  7. 7.
    Brook I, Dohar JE. Management of group A beta-hemolytic streptococcal pharyngotonsillitis in children. J Fam Pract. 2006;55(12):S1–11. quiz S12.PubMedGoogle Scholar
  8. 8.
    Randolph MF, Gerber MA, DeMeo KK, Wright L. Effect of antibiotic therapy on the clinical course of streptococcal pharyngitis. J Pediatr. 1985;106:870–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Krober MS, Bass JW, Michels GN. Streptococcal pharyngitis: placebo-controlled double-blind evaluation of clinical response to penicillin therapy. JAMA. 1985;253:1271–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Nelson JD. The effect of penicillin therapy on the symptoms and signs of streptococcal pharyngitis. Pediatr Infect Dis J. 1984;3:10–3.CrossRefGoogle Scholar
  11. 11.
    Salkind AR, Wright JM. Economic burden of adult pharyngitis: the payer’s perspective. ISPOR. 2008;11:621–7.Google Scholar
  12. 12.
    Wannamaker LW. Perplexity and precision in the diagnosis of streptococcal pharyngitis. Am J Dis Child. 1972;124(3):352–8.PubMedGoogle Scholar
  13. 13.
    Kaplan EL, Top FH Jr, Dudding BA, Wannamaker LW. Diagnosis of streptococcal pharyngitis: differentiation of active infection from the carrier state in the symptomatic child. J Infect Dis. 1971;123(5):490–501.PubMedCrossRefGoogle Scholar
  14. 14.
    Breese BB, Disney FA. The accuracy of diagnosis of beta-streptococcal infections on clinical grounds. J Pediatr. 1954;44:670–3.PubMedCrossRefGoogle Scholar
  15. 15.
    Pokorski SJ, Vetter EA, Wollan PC, Cockerill FR 3rd. Comparison of Gen-Probe Group A streptococcus Direct Test with culture for diagnosing streptococcal pharyngitis. J Clin Microbiol. 1994;32:1440–3.PubMedGoogle Scholar
  16. 16.
    Heelan JS, Wilbur S, Depetris G, Letourneau C. Rapid antigen testing for group A Streptococcus by DNA probe. Diagn Microbiol Infect Dis. 1996;24:65–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Gerber MA. Comparison of throat cultures and rapid strep tests for diagnosis of streptococcal pharyngitis. Pediatr Infect Dis J. 1989;8:820–4.PubMedCrossRefGoogle Scholar
  18. 18.
    Chapin KC, Blake P, Wilson CD. Performance characteristics and utilization of rapid antigen test, DNA probe, and culture for detection of group a streptococci in an acute care clinic. J Clin Microbiol. 2002;40(11):4207–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Rogo T, Schwartz RH, Ascher DP. Comparison of the Inverness Medical Acceava Strep A test with the Genzyme OSOM and Quidel QuickVue Strep A tests. Clin Pediatr. 2011;50:294–6.CrossRefGoogle Scholar
  20. 20.
    Bourbeau PP, Heiter BJ. Use of swabs without transport media for the Gen-Probe Group A Strep Direct Test. J Clin Microbiol. 2004;42:3207–11.PubMedCrossRefGoogle Scholar
  21. 21.
    Peter GS, Bisno AL. Group A streptococcal pharyngitis in adults: diagnosis and management. In: Pechera JC, Kaplan EL, eds. Streptococcal pharyngitis issues in infectious diseases. Basel. Karger. 2004;3:22.Google Scholar
  22. 22.
    Poses RM, Cebul RD, Collins M, Fager SS. The accuracy of experienced physicians’ probability estimates for patients with sore throats. Implications for decision making. JAMA. 1985;254:925.PubMedCrossRefGoogle Scholar
  23. 23.
    Woods WA, Carter CT, Stack M, et al. Group A streptococcal pharyngitis in adults 30 to 65 years of age. South Med J. 1999;92:491.PubMedCrossRefGoogle Scholar
  24. 24.
    Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989–1999. JAMA. 2001;286:1181.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  1. 1.Cleveland Clinic FoundationClevelandUSA

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