今日の臨床サポート

咽頭痛

著者: 五十嵐博 武蔵国分寺公園クリニック

監修: 名郷直樹 武蔵国分寺公園クリニック

著者校正/監修レビュー済:2022/08/17
患者向け説明資料

概要・推奨   

  1. 溶連菌に対する臨床診断の感度・特異度は、感度55~74%、特異度58~74%と報告されており、臨床診断で確定や除外はできない(推奨度1)
  1. 溶連菌迅速診断キットは、感度86%、特異度96%と 、陽性のときに溶連菌と判断してよい。陰性の場合には溶連菌を除外できないものの、日本をはじめとしたリウマチ熱の罹患率が低い地域では、多くの場合咽頭培養の提出は必須ではない(推奨度2)
  1. 咽頭培養は溶連菌感染に対して感度90~95%である(推奨度3)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
五十嵐博 : 原稿料(エイチ・ツー・オー綜合研究所)[2022年]
監修:名郷直樹 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 溶連菌迅速診断キットの感度、特異度は最新のメタ分析の結果を記載し、迅速診断キット陰性であれば、多くの場合咽頭培養の提出は必須ではないとした。
  1. 新型コロナウイルス感染症流行中は、全例で新型コロナウイルスPCR検査を推奨した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 咽頭痛は外来診療で最も頻繁に接する症状の1つで初診時のすべての問題の4.6%という報告がある。
  1. 原因の大部分は感染症で、急性扁桃炎は新しい健康問題の1.1%を占めると報告されている。
  1. 抗菌薬によって治療可能でリウマチ熱の予防が重要なA群β溶連菌は10-15%でその診断が重要である。
  1. その反面、咽頭痛患者の70%に投与されているという不要な抗菌薬投与を防ぐための溶連菌感染の除外が重要である。
  1. 見逃すと生命に危険を及ぼす喉頭蓋炎、扁桃周囲膿瘍、頚部の膿瘍の除外が重要である。
  1. 溶連菌以外の治療可能なものとしては、マイコプラズマ、クラミジア、淋菌、インフルエンザ、新型コロナウイルス感染症、単純ヘルペス、ジフテリア、HIVがある。
  1. 感染以外では亜急性甲状腺炎を念頭に置く。
 
  1. 咽頭痛の頻度は新規の訴えのうち4.6%を占め、急性扁桃炎の診断は新規に診断された疾患の1.1%を占める(推奨度1)(参考文献:[1]
  1. 頻度についての報告は少ないが、外来における問題と診断をICPCでコード化した報告がある。
 
  1. 成人の咽頭痛患者中、溶連菌感染症患者の割合は10~15%だが、抗菌薬の処方割合は70%に上る(推奨度2)(参考文献:[2][3]
  1. 成人の咽頭痛患者中、溶連菌患者の大部分は溶連菌ではないが、抗菌薬が投与されており、過剰投与が問題である。American College of Physicianは、溶連菌の確認なしに抗菌薬を投与すべきでないとの勧告をしている[4]
 
  1. 臨床診断での感度・特異度は、感度55~74%、特異度58~74%と報告されており、溶連菌感染かどうか確定したり、除外したりすることはできない。臨床診断のみに基づくと、Centorスコア3-4点の患者であっても、不要な抗菌薬投与が32~44%に上ると報告されている(推奨度1)(参考文献:[5][6][7]
  1. 病歴、診察:発熱、頚部リンパ節腫脹、咳なし、扁桃炎の所見というCentorスコアが有名だが、2点以上の状況では意思決定をすることはできず、その他の臨床情報、検査の希望、流行状況などを考慮して検査するかどうかを決める必要がある。
  1. 迅速診断キットを行うかどうかは、その時点での事前確率の見積もり、診断閾値、治療閾値を個別の状況でどう考えるかによる。
  1. 臨床診断のみで抗菌薬の適応を考える場合、抗菌薬の過剰投与に傾きやすい。
  1. より高齢で、溶連菌自体の可能性が低く、さらにはリウマチ熱の可能性も低い状況では、溶連菌に抗菌薬を投与しないための配慮より、過剰投与を減らす努力が重要で、迅速検査の結果で判断する局面が多くなるだろう。
問診・診察のポイント  
  1. 発熱の有無、経過を聞く。

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文献 

V Snow, C Mottur-Pilson, R J Cooper, J R Hoffman, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, Centers for Disease Control
Principles of appropriate antibiotic use for acute pharyngitis in adults.
Ann Intern Med. 2001 Mar 20;134(6):506-8.
Abstract/Text
PMID 11255529
Stanford T Shulman, Alan L Bisno, Herbert W Clegg, Michael A Gerber, Edward L Kaplan, Grace Lee, Judith M Martin, Chris Van Beneden, Infectious Diseases Society of America
Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2012 Nov 15;55(10):e86-102. doi: 10.1093/cid/cis629. Epub 2012 Sep 9.
Abstract/Text The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

PMID 22965026
Aaron M Harris, Lauri A Hicks, Amir Qaseem, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention
Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention.
Ann Intern Med. 2016 Mar 15;164(6):425-34. doi: 10.7326/M15-1840. Epub 2016 Jan 19.
Abstract/Text BACKGROUND: Acute respiratory tract infection (ARTI) is the most common reason for antibiotic prescription in adults. Antibiotics are often inappropriately prescribed for patients with ARTI. This article presents best practices for antibiotic use in healthy adults (those without chronic lung disease or immunocompromising conditions) presenting with ARTI.
METHODS: A narrative literature review of evidence about appropriate antibiotic use for ARTI in adults was conducted. The most recent clinical guidelines from professional societies were complemented by meta-analyses, systematic reviews, and randomized clinical trials. To identify evidence-based articles, the Cochrane Library, PubMed, MEDLINE, and EMBASE were searched through September 2015 using the following Medical Subject Headings terms: "acute bronchitis," "respiratory tract infection," "pharyngitis," "rhinosinusitis," and "the common cold."
HIGH-VALUE CARE ADVICE 1: Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected.
HIGH-VALUE CARE ADVICE 2: Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
HIGH-VALUE CARE ADVICE 3: Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening).
HIGH-VALUE CARE ADVICE 4: Clinicians should not prescribe antibiotics for patients with the common cold.

PMID 26785402
R J Cooper, J R Hoffman, J G Bartlett, R E Besser, R Gonzales, J M Hickner, M A Sande, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, Centers for Disease Control
Principles of appropriate antibiotic use for acute pharyngitis in adults: background.
Ann Intern Med. 2001 Mar 20;134(6):509-17.
Abstract/Text The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus.1. Group A beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed.2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care.3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis). Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; b) test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria. 4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when such pathogens as gonococcus are being considered.5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient.

PMID 11255530
Jean-Paul Humair, Sylvie Antonini Revaz, Patrick Bovier, Hans Stalder
Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings.
Arch Intern Med. 2006 Mar 27;166(6):640-4. doi: 10.1001/archinte.166.6.640.
Abstract/Text BACKGROUND: How to use clinical score, the rapid streptococcal antigen test (RSAT), and culture results is uncertain for efficient management of acute pharyngitis in adults.
METHODS: This prospective cohort study included 372 adult patients with pharyngitis treated at a Swiss university-based primary care clinic. In eligible patients with 2 to 4 clinical symptoms and signs (temperature >or=38 degrees C, tonsillar exudate, tender cervical adenopathy, and no cough or rhinitis), we performed an RSAT and obtained a throat culture. We measured sensitivity and specificity of RSAT with culture as a gold standard and compared appropriate antibiotic use with cost per patient appropriately treated for the following 5 strategies: symptomatic treatment, systematic RSAT, selective RSAT, empirical antibiotic treatment, and systematic culture.
RESULTS: RSAT had high sensitivity (91%) and specificity (95%) for the diagnosis of streptococcal pharyngitis. Systematic throat culture resulted in the highest antibiotic use, in 38% of patients with streptococcal pharyngitis. Systematic RSAT led to nearly optimal treatment (94%) and antibiotic prescription (37%), with minimal antibiotic overuse (3%) and underuse (3%). Empirical antibiotic treatment in patients with 3 or 4 clinical symptoms or signs resulted in a lower rate of appropriate therapy (59%) but higher rates of antibiotic use (60%), overuse (32%), and underuse (9%). Systematic RSAT was more cost-effective than strategies based on empirical treatment or culture: 15.00 dollars, 26.00 dollars, and 32.00 dollars, respectively, per patient appropriately treated.
CONCLUSIONS: The RSAT we used is a valid test for diagnosis of pharyngitis in adults. A clinical approach combining this RSAT and clinical findings efficiently reduces inappropriate antibiotic prescription in adult patients with acute pharyngitis. Empirical therapy in patients with 3 or 4 clinical symptoms or signs results in antibiotic overuse.

PMID 16567603
Warren J McIsaac, James D Kellner, Peggy Aufricht, Anita Vanjaka, Donald E Low
Empirical validation of guidelines for the management of pharyngitis in children and adults.
JAMA. 2004 Apr 7;291(13):1587-95. doi: 10.1001/jama.291.13.1587.
Abstract/Text CONTEXT: Recent guidelines for management of pharyngitis vary in their recommendations concerning empirical antibiotic treatment and the need for laboratory confirmation of group A streptococcus (GAS).
OBJECTIVE: To assess the impact of guideline recommendations and alternative approaches on identification and treatment of GAS pharyngitis in children and adults.
DESIGN, SETTING, AND PARTICIPANTS: Throat cultures and rapid antigen tests were performed on 787 children and adults aged 3 to 69 years with acute sore throat attending a family medicine clinic in Calgary, Alberta, from September 1999 to August 2002. Recommendations from 2 guidelines (those of the Infectious Diseases Society of America and of the American College of Physicians-American Society of Internal Medicine/American Academy of Family Physicians/US Centers for Disease Control and Prevention) were compared with rapid testing alone, a clinical prediction rule (ie, the modified Centor score), and a criterion standard of treatment for positive throat culture results only.
MAIN OUTCOME MEASURES: Sensitivity and specificity of each strategy for identifying GAS pharyngitis, total antibiotics recommended, and unnecessary antibiotic prescriptions.
RESULTS: In children, sensitivity for streptococcal infection ranged from 85.8% (133/155; 95% confidence interval [CI], 79.3%-90.0%) for rapid testing to 100% for culturing all. In adults, sensitivity ranged from 76.7% (56/73; 95% CI, 65.4%-85.8%) for rapid testing without culture confirmation of negative results to 100% for culturing all. In children, specificity ranged from 90.3% (270/299; 95% CI, 86.4%-93.4%) for use of modified Centor score and throat culture to 100% for culturing all. In adults, specificity ranged from 43.8% (114/260; 95% CI, 37.7%-50.1%) for empirical treatment based on a modified Centor score of 3 or 4 to 100% for culturing all. Total antibiotic prescriptions were lowest with rapid testing (24.7% [194/787]; 95% CI, 21.7%-27.8%) and highest with empirical treatment of high-risk adults (45.7% [360/787]; 95% CI, 42.2%-49.3%), due to a high rate of unnecessary prescriptions in adults (43.8% [146/333]; 95% CI, 38.4%-49.4%).
CONCLUSIONS: Guideline recommendations for the selective use of throat cultures but antibiotic treatment based only on positive rapid test or throat culture results can reduce unnecessary use of antibiotics for treatment of pharyngitis. However, empirical treatment of adults having a Centor score of 3 or 4 is associated with a high rate of unnecessary antibiotic use. In children, strategies incorporating throat culture or throat culture confirmation of negative rapid antigen test results are highly sensitive and specific. Throat culture of all adults or those selected on the basis of a clinical prediction rule had the highest sensitivity and specificity.

PMID 15069046
Simone de Cassan, Matthew J Thompson, Rafael Perera, Paul P Glasziou, Chris B Del Mar, Carl J Heneghan, Gail Hayward
Corticosteroids as standalone or add-on treatment for sore throat.
Cochrane Database Syst Rev. 2020 May 1;5:CD008268. doi: 10.1002/14651858.CD008268.pub3. Epub 2020 May 1.
Abstract/Text BACKGROUND: Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract. This review is an update to our review published in 2012.
OBJECTIVES: To assess the clinical benefit and safety of corticosteroids in reducing the symptoms of sore throat in adults and children.
SEARCH METHODS: We searched CENTRAL (Issue 4, 2019), MEDLINE (1966 to 14 May 2019), Embase (1974 to 14 May 2019), the Database of Abstracts of Reviews of Effects (DARE, 2002 to 2015), and the NHS Economic Evaluation Database (inception to 2015). We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared steroids to either placebo or standard care in adults and children (aged over three years) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis (glandular fever), sore throat following tonsillectomy or intubation, or peritonsillar abscess.
DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane.
MAIN RESULTS: We included one new RCT in this update, for a total of nine trials involving 1319 participants (369 children and 950 adults). In eight trials, participants in both corticosteroid and placebo groups received antibiotics; one trial offered delayed prescription of antibiotics based on clinical assessment. Only two trials reported funding sources (government and a university foundation). In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by 2.40 times (risk ratio (RR) 2.4, 95% confidence interval (CI) 1.29 to 4.47; P = 0.006; I² = 67%; high-certainty evidence) and at 48 hours by 1.5 times (RR 1.50, 95% CI 1.27 to 1.76; P < 0.001; I² = 0%; high-certainty evidence). Five people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 11.6 hours, respectively, although significant heterogeneity was present (moderate-certainty evidence). At 24 hours, pain (assessed by visual analogue scales) was reduced by an additional 10.6% by corticosteroids (moderate-certainty evidence). No differences were reported in recurrence/relapse rates, days missed from work or school, or adverse events for participants taking corticosteroids compared to placebo. However, the reporting of adverse events was poor, and only two trials included children or reported days missed from work or school. The included studies were assessed as moderate quality evidence, but the small number of included studies has the potential to increase the uncertainty, particularly in terms of applying these results to children.
AUTHORS' CONCLUSIONS: Oral or intramuscular corticosteroids, in addition to antibiotics, moderately increased the likelihood of both resolution and improvement of pain in participants with sore throat. Given the limited benefit, further research into the harms and benefits of short courses of steroids is needed to permit informed decision-making.

Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
PMID 32356360
Gail Nicola Hayward, Alastair D Hay, Michael V Moore, Sena Jawad, Nicola Williams, Merryn Voysey, Johanna Cook, Julie Allen, Matthew Thompson, Paul Little, Rafael Perera, Jane Wolstenholme, Kim Harman, Carl Heneghan
Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial.
JAMA. 2017 Apr 18;317(15):1535-1543. doi: 10.1001/jama.2017.3417.
Abstract/Text Importance: Acute sore throat poses a significant burden on primary care and is a source of inappropriate antibiotic prescribing. Corticosteroids could be an alternative symptomatic treatment.
Objective: To assess the clinical effectiveness of oral corticosteroids for acute sore throat in the absence of antibiotics.
Design, Setting, and Participants: Double-blind, placebo-controlled randomized trial (April 2013-February 2015; 28-day follow-up completed April 2015) conducted in 42 family practices in South and West England, enrolled 576 adults recruited on the day of presentation to primary care with acute sore throat not requiring immediate antibiotic therapy.
Interventions: Single oral dose of 10 mg of dexamethasone (n = 293) or identical placebo (n = 283).
Main Outcomes and Measures: Primary: proportion of participants experiencing complete resolution of symptoms at 24 hours. Secondary: complete resolution at 48 hours, duration of moderately bad symptoms (based on a Likert scale, 0, normal; 6, as bad as it could be), visual analog symptom scales (0-100 mm; 0, no symptom to 100, worst imaginable), health care attendance, days missed from work or education, consumption of delayed antibiotics or other medications, adverse events.
Results: Among 565 eligible participants who were randomized (median age, 34 years [interquartile range, 26.0-45.5 year]; 75.2% women; 100% completed the intervention), 288 received dexamethasone; 277, placebo. At 24 hours, 65 participants (22.6%) in the dexamethasone group and 49 (17.7%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 4.7% (95% CI, -1.8% to 11.2%) and a relative risk of 1.28 (95% CI; 0.92 to 1.78; P = .14). At 24 hours, participants receiving dexamethasone were not more likely than those receiving placebo to have complete symptom resolution. At 48 hours, 102 participants (35.4%) in the dexamethasone group vs 75 (27.1%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 8.7% (95% CI, 1.2% to 16.2%) and a relative risk of 1.31 (95% CI, 1.02 to 1.68; P = .03). This difference also was observed in participants not offered delayed antibiotic prescription, for a risk difference of 10.3% (95% CI, 0.6% to 20.1%) and a relative risk of 1.37 (95% CI, 1.01 to 1.87; P = .046). There were no significant differences in any other secondary outcomes.
Conclusions and Relevance: Among adults presenting to primary care with acute sore throat, a single dose of oral dexamethasone compared with placebo did not increase the proportion of patients with resolution of symptoms at 24 hours. However, there was a significant difference at 48 hours.
Trial Registration: isrctn.org Identifier: ISRCTN17435450.

PMID 28418482
Anneliese Spinks, Paul P Glasziou, Chris B Del Mar
Antibiotics for sore throat.
Cochrane Database Syst Rev. 2013 Nov 5;(11):CD000023. doi: 10.1002/14651858.CD000023.pub4. Epub 2013 Nov 5.
Abstract/Text BACKGROUND: Sore throat is a common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it.
OBJECTIVES: To assess the benefits of antibiotics for sore throat for patients in primary care settings.
SEARCH METHODS: We searched CENTRAL 2013, Issue 6, MEDLINE (January 1966 to July week 1, 2013) and EMBASE (January 1990 to July 2013).
SELECTION CRITERIA: Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications.
DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. We contacted trial authors from three studies for additional information.
MAIN RESULTS: We included 27 trials with 12,835 cases of sore throat. We did not identify any new trials in this 2013 update. 1. Symptoms Throat soreness and fever were reduced by about half by using antibiotics. The greatest difference was seen at day three. The number needed to treat to benefit (NNTB) to prevent one sore throat at day three was less than six; at week one it was 21. 2. Non-suppurative complications The trend was antibiotics protecting against acute glomerulonephritis but there were too few cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two-thirds within one month (risk ratio (RR) 0.27; 95% confidence interval (CI) 0.12 to 0.60). 3. Suppurative complications Antibiotics reduced the incidence of acute otitis media within 14 days (RR 0.30; 95% CI 0.15 to 0.58); acute sinusitis within 14 days (RR 0.48; 95% CI 0.08 to 2.76); and quinsy within two months (RR 0.15; 95% CI 0.05 to 0.47) compared to those taking placebo. 4. Subgroup analyses of symptom reduction Antibiotics were more effective against symptoms at day three (RR 0.58; 95% CI 0.48 to 0.71) if throat swabs were positive for Streptococcus, compared to RR 0.78; 95% CI 0.63 to 0.97 if negative. Similarly at week one the RR was 0.29 (95% CI 0.12 to 0.70) for positive and 0.73 (95% CI 0.50 to 1.07) for negative Streptococcus swabs.
AUTHORS' CONCLUSIONS: Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to benefit. This NNTB may be lower in low-income countries. Antibiotics shorten the duration of symptoms by about 16 hours overall.

PMID 24190439
Wei Ling Lean, Sarah Arnup, Margie Danchin, Andrew C Steer
Rapid diagnostic tests for group A streptococcal pharyngitis: a meta-analysis.
Pediatrics. 2014 Oct;134(4):771-81. doi: 10.1542/peds.2014-1094. Epub 2014 Sep 8.
Abstract/Text BACKGROUND AND OBJECTIVE: Effective management of group A streptococcal (GAS) pharyngitis is hindered by impracticality of the gold standard diagnostic test: throat culture. Rapid antigen diagnostic tests (RADTs) are a promising alternative, although concerns about their sensitivity and specificity, and variation between test methodologies, have limited their clinical use. The objective of this study was to perform a systematic review with meta-analysis of the diagnostic accuracy of RADTs for GAS pharyngitis.
METHODS: Medline and Embase from 1996 to 2013 were used as data sources. Of 159 identified studies, 48 studies of diagnostic accuracy of GAS RADTs using throat culture on blood agar as a reference standard were selected. Bivariate random-effects regression was used to estimate sensitivity and specificity with 95% confidence intervals (CIs). Additional meta-analyses were performed for pediatric data.
RESULTS: A total of 60 pairs of sensitivity and specificity from 48 studies were included. Overall summary estimates for sensitivity and specificity of RADTs were 0.86 (95% CI 0.83 to 0.88) and 0.96 (95% CI 0.94 to 0.97), respectively, and estimates for pediatric data were similar. Molecular-based RADTs had the best diagnostic accuracy. Considerable variability exists in methodology between studies. There were insufficient studies to allow meta-regression/subgroup analysis within each test type.
CONCLUSIONS: RADTs can be used for accurate diagnosis of GAS pharyngitis to streamline management of sore throat in primary care. RADTs may not require culture backup for negative tests in most low-incidence rheumatic fever settings. Newer molecular tests have the highest sensitivity, but are not true point-of-care tests.

Copyright © 2014 by the American Academy of Pediatrics.
PMID 25201792
Jérémie F Cohen, Nathalie Bertille, Robert Cohen, Martin Chalumeau
Rapid antigen detection test for group A streptococcus in children with pharyngitis.
Cochrane Database Syst Rev. 2016 Jul 4;7:CD010502. doi: 10.1002/14651858.CD010502.pub2. Epub 2016 Jul 4.
Abstract/Text BACKGROUND: Group A streptococcus (GAS) accounts for 20% to 40% of cases of pharyngitis in children; the remaining cases are caused by viruses. Compared with throat culture, rapid antigen detection tests (RADTs) offer diagnosis at the point of care (within five to 10 minutes).
OBJECTIVES: To determine the diagnostic accuracy of RADTs for diagnosing GAS in children with pharyngitis. To assess the relative diagnostic accuracy of the two major types of RADTs (enzyme immunoassays (EIA) and optical immunoassays (OIA)) by indirect and direct comparison.
SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, Web of Science, CDSR, DARE, MEDION and TRIP (January 1980 to July 2015). We also conducted related citations tracking via PubMed, handsearched reference lists of included studies and relevant review articles, and screened all articles citing included studies via Google Scholar.
SELECTION CRITERIA: We included studies that compared RADT for GAS pharyngitis with throat culture on a blood agar plate in a microbiology laboratory in children seen in ambulatory care.
DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for relevance, assessed full texts for inclusion, and carried out data extraction and quality assessment using the QUADAS-2 tool. We used bivariate meta-analysis to estimate summary sensitivity and specificity, and to investigate heterogeneity across studies. We compared the accuracy of EIA and OIA tests using indirect and direct evidence.
MAIN RESULTS: We included 98 unique studies in the review (116 test evaluations; 101,121 participants). The overall methodological quality of included studies was poor, mainly because many studies were at high risk of bias regarding patient selection and the reference standard used (in 73% and 43% of test evaluations, respectively). In studies in which all participants underwent both RADT and throat culture (105 test evaluations; 58,244 participants; median prevalence of participants with GAS was 29.5%), RADT had a summary sensitivity of 85.6%; 95% confidence interval (CI) 83.3 to 87.6 and a summary specificity of 95.4%; 95% CI 94.5 to 96.2. There was substantial heterogeneity in sensitivity across studies; specificity was more stable. There was no evidence of a trade-off between sensitivity and specificity. Heterogeneity in accuracy was not explained by study-level characteristics such as whether an enrichment broth was used before plating, mean age and clinical severity of participants, and GAS prevalence. The sensitivity of EIA and OIA tests was comparable (summary sensitivity 85.4% versus 86.2%). Sensitivity analyses showed that summary estimates of sensitivity and specificity were stable in low risk of bias studies.
AUTHORS' CONCLUSIONS: In a population of 1000 children with a GAS prevalence of 30%, 43 patients with GAS will be missed. Whether or not RADT can be used as a stand-alone test to rule out GAS will depend mainly on the epidemiological context. The sensitivity of EIA and OIA tests seems comparable. RADT specificity is sufficiently high to ensure against unnecessary use of antibiotics. Based on these results, we would expect that amongst 100 children with strep throat, 86 would be correctly detected with the rapid test while 14 would be missed and not receive antibiotic treatment.

PMID 27374000
Abstract/Text BACKGROUND: Optimal diagnostic management of patients with pharyngitis is controversial. In our study, we compared streptococcal complication rates at a large suburban medical center during 2 time periods: when pharyngitis patients were managed almost exclusively with throat culture and when they were managed primarily with a high-sensitivity antigen test without culture confirmation of negative results.
METHODS: Using a combination of Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes, we studied all patients seen for either pharyngitis or known streptococcal complications during a 4-year period. We then reviewed all available charts of patients with known streptococcal complications for coding accuracy. We compared streptococcal complication rates during each -time period.
RESULTS: A total of 30,036 patients were seen for pharyngitis during the 4 years. A streptococcal diagnostic test was used in 66% of patient encounters. During the first 2 years (period 1), 99.9% of the tests ordered were blood agar plate throat cultures. During the second 2 years (period 2), 76.6% of tests ordered were high-sensitivity antigen tests without culture confirmation of negative results. Suppurative complications occurred in 37 patients in period 1 and 36 patients in period 2. There were no cases of acute rheumatic fever in either period. There was one case of poststreptococcal glomerulonephritis in period 2.
CONCLUSIONS: Use of a high-sensitivity antigen test without culture confirmation of all negative results has not been associated with an increase in suppurative and nonsuppurative complications of group A beta-hemolytic streptococci.

PMID 10678338

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