Self help pediatrico

Brief Summary

GUIDELINE TITLE
Acute pharyngitis.

BIBLIOGRAPHIC SOURCE(S)
· Institute for Clinical Systems Improvement (ICSI). Acute pharyngitis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2005 May. 33 p. [39 references]

GUIDELINE STATUS
This is the current release of the guideline.
This guideline updates a previous version: Acute pharyngitis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2003 May. 27 p.
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Perform Rapid Strep Test (RST)
Strep Culture (STCX)
Key Points:
· Empiric treatment of GABS is discouraged due to poor diagnostic accuracy even with elaborate clinical scoring systems.
· RST is useful but does not have sufficient sensitivity to be used alone.
· STCX is the most sensitive test for GABS but treatment needs to be delayed until the test results are available.
· RST followed by STCX has the highest positive predictive value that the patient actually has the illness.
RST and STCX both require proper collection technique by trained professionals and must be performed according to the Federal Clinical Laboratory Improvement Act (CLIA) regulations. Poor collection procedures reduce accuracy of either test. RST must also be performed according to the manufacturer's guidelines. An appropriately performed throat swab touches both tonsillar pillars and the posterior pharyngeal wall. The tongue should not be included (although its avoidance is sometimes technically impossible). Backup STCX is needed if the RST is negative. The best yield is obtained by using separate swabs for RST and STCX.
If RST is not available, STCX (culture to determine the absence or presence of GABS) should be performed. Generally treatment should be delayed until STCX results are available. Results are usually available within 24 hours or slightly less, but may require incubation for longer periods of time. Some clinicians choose to initiate treatment prior to culture result availability, but a full course of treatment should not be prescribed until culture results confirm the presence of GABS.
A less satisfactory strategy is empiric treatment. Using complex clinical scoring systems or in patients with the complete constellation of classic strep symptoms, empiric treatment may be justified, but it has significant limitations. If full course treatment is initiated without intent to rely on the test results, laboratory testing is redundant and wasteful. Routinely culturing and prescribing antibiotic treatment for asymptomatic family members is not recommended. Routinely reculturing patients after treatment with antibiotics is not recommended.
Evidence supporting this recommendation (clinical scoring system) is of class: C
Evidence supporting this recommendation (RST and STCX) is of classes: C, M, R
STCX Result
Whether or not the test is positive, patients and their families want to know results as soon as possible so that they can appropriately plan for their needs.
· If negative, they need educational information and a planned course of action if they do not recover in a reasonable time frame or if they become more ill.
· If positive, patients want to be started on medication as rapidly as possible, primarily as a comfort or convenience issue and to reduce contagion. Rheumatic fever prophylaxis is likely satisfactory if started within a week of the positive culture; however, patients and parents may perceive any delay in initiation of treatment as poor service.

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