Acute Pharyngitis Clinical Trial
Official title:
Pakistan Epidemiological Survey in Acute Pharyngitis
GABHS are common etiological agents for acute pharyngitis. However, local data is limited
and large scale surveillance studies have not been done. This study aims to evaluate the
disease burden in the community due to GABHS.
In this study, patients presenting with signs of acute pharyngitis will be evaluated.
Patients with fulfilling the inclusion criteria will be tested for Rapid Antigen Detection
test (RADT)
Pharyngitis is a common reason for patients' visit to doctors. Group A beta- hemolytic
streptococci (GABHS) account for 15-30 percent of cases of acute pharyngitis in children and
5 to 20 percent in adults1.
Because the signs and symptoms of GABHS pharyngitis overlap extensively with other
infectious causes, making a diagnosis based solely on clinical findings is difficult. In
patients with acute febrile respiratory illness, physicians accurately differentiate
bacterial from viral infections using only the history and physical findings about one half
of the time.2 No single element of the patient's history or physical examination reliably
confirms or excludes GABHS pharyngitis.3 Sore throat, fever with sudden onset (temperature
greater than 100.4° F [38° C]), and exposure to Streptococcus within the preceding two weeks
suggest GABHS infection. Cervical node lymphadenopathy and pharyngeal or tonsillar
inflammation or exudates are common signs. Palatal petechiae and scarlatiniform rash are
highly specific but uncommon; a swollen uvula is sometimes noted. Cough, coryza,
conjunctivitis, and diarrhea are more common with viral pharyngitis.
The original Centor score uses four signs and symptoms to estimate the probability of acute
streptococcal pharyngitis in adults with a sore throat.4 The score was later modified by
adding age and validated in 600 adults and children.5,6 The cumulative score determines the
likelihood of streptococcal pharyngitis.
Rapid Antigen Detection Tests (RADTs) have been developed for the identification of GABHS
directly from throat swabs. Although these rapid tests are more expensive than blood agar
culture, they provide results faster. Rapid identification and treatment of patients with
streptococcal pharyngitis can reduce the risk of the spread of group A b-hemolytic
streptococci, allowing the patient to return to school or work sooner, and can reduce the
acute morbidity associated with the illness. The use of RADTs for certain populations (e.g.,
patients in emergency departments) has been shown to significantly increase the number of
patients who are appropriately treated for streptococcal pharyngitis, compared with use of
traditional throat cultures.7
The great majority of the RADTs that are currently available have an excellent specificity
of 95%, compared with blood agar plate culture. This means that false-positive test results
are unusual, and, therefore, therapeutic decisions can be made with confidence on the basis
of a positive test result. Unfortunately, the sensitivity of most of these tests is 80%-90%,
or even lower, compared with blood agar plate culture. It has been suggested that most of
the false-negative RADT results occur for patients who are merely Streptococcus carriers and
are not truly infected. However, early studies of first-generation RADTs demonstrated that a
large proportion of patients with false-negative RADT results were truly infected with group
A b-hemolytic streptococci and were not merely carriers.8
Acute pharyngitis is commonly encountered in clinics and hospitals across Pakistan. It is
common not only in children but also among adults. Limited data are available on the
prevalence of this condition and existing data are from small single center based studies.
The available data from Pakistan suggest that the most common bacterial organism is GABHS,
however, majority of throat swabs did not yield any isolate.9 The signs and symptoms of
GABHS pharyngitis overlap extensively with other infectious causes, thus to make an
etiologic diagnosis based solely on clinical findings is difficult. Improving diagnosis of
bacterial causes of pharyngitis will lead to more rational use of antibiotics among
clinicians, and potentially have a positive impact on the development of bacterial
resistance in community acquired infections.
The modified Centor score is a valid tool to estimate the probability of acute streptococcal
pharyngitis in patients with a sore throat. (reference) Patients with a score of zero or 1
are at very low risk for streptococcal pharyngitis and do not require testing (i.e., throat
culture or rapid antigen detection testing [RADT]) or antibiotic therapy. Patients with a
score of 2 or 3 should be tested using RADT or throat culture; positive results warrant
antibiotic therapy. Patients with a score of 4 or higher are at high risk of streptococcal
pharyngitis, and empiric treatment may be considered. (reference)
RADT allows for earlier treatment, symptom improvement, and reduced disease spread.
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Observational Model: Case-Only, Time Perspective: Prospective
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