Pediatric ENT in Minutes

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					Pediatric ENT in 40 Minutes

      Gil C. Grimes, MD
          April 2007
Objectives
   Describe criteria for diagnosing Acute Otitis
    Media
   Describe rationale for therapy for Acute Otitis
    Media
   Describe Therapy for Serous Otitis Media
   Describe the role of Tympanostomy Tubes
   Describe the strategies for diagnosing Strep
    Pharyngitis
   Describe Treatment options for Strep Pharyngitis
My Bias
   I am a minimalist



   If the evidence for
    intervention is not
    good I do nothing
    Acute Otitis Media
        A diagnosis of AOM requires
              a history of acute onset of signs and
               symptoms
              the presence of middle ear effusion (MEE)
              signs and symptoms of middle-ear
               inflammation.



Pediatrics 2004 May;113(5):1451-65   Level 1a
Acute Otitis Media
   The presence of MEE that is indicated
    by any of the following:
       Bulging of the tympanic membrane
       Limited or absent mobility of the tympanic
        membrane
       Air-fluid level behind the tympanic
        membrane
       Otorrhea
Acute Otitis Media
   Signs or symptoms of middle-ear
    inflammation as indicated by either
     Distinct erythema of the tympanic
      membrane
    or
     Distinct otalgia

           discomfort clearly referable to the ear(s) and
           interference with or precludes normal activity
            or sleep
     Acute Otitis Media
         Otitis Media?
               Yes
               No




http://www.otol.uic.edu/research/microto/Microtoscopy/Case10origweb.jpg
Acute Otitis Media
   Otitis Media?
       Yes
       No




                    www.orldoc.ch/index
             Acute Otitis Media Prevalence
                  Prevalence
                        10% US children diagnosed by 3 months
                        90% by 2 years (1)
                        Prospective cohort of children (2)
                              62% with AOM by 1 year
                              83% with AOM by 3 years
                        9th most common diagnosis during FM
                         visits(3)
                        Coded 3.2% visits (3)
1)Pediatric Infect Dis J 1989 Jan;8(1 Suppl):S9 Level 2b
2)J Infect Dis 1989 Jul;160(1):83 Level 2b
3) Ann fam Med 2004 Sep-Oct:2(5)411 Level 2c
    Acute Otitis Media Etiology
        Viral pathogens found Tympanocentesis and Nasal
         Aspirate in AOM
           RSV and coronavirus RNA in 75% children

                    5% dual viral infections


              Bacterial pathogens detected 62%

              Viral RNA detected in 57% bacteria-negative and
               45% bacteria-positive samples


Pediatrics 1998 Aug;102(2):291 Level 1c
      Acute Otitis Media Etiology
           Bacteria shifts
                 Streptococcus pneumoniae
                       S. pneumoniae is the most common bacterial organism
                        identified
                 non-typeable Haemophilus influenzae
                       H. flu identified primarily in children < 5, but reduced with
                        routine immunization
                 Moraxella (Branhamella) catarrhalis

           May be changing due to heptavalent pneumococcal
            vaccine
                 decrease in S. pneumoniae and increase in H. influenzae


Pediatric Infectious Disease 2004 Sep;23(9):824 Level 2b
Acute Otitis Media Risk Factors
   Formula feeding
         incidence of otitis media is higher in
          formula-fed infants vs. breast-fed infants

         incidence of prolonged ear infections was
          5x higher among formula-fed infants

         Duration OM episodes longer (8.8 vs. 5.9
          days)
J Pediatric 1995 May;126(5 Pt 1):696 Level 2b
Acute Otitis Media Risk Factors
   Day Care Attendance
         day care associated with increased risk of upper
          and lower respiratory tract illnesses in first year of
          life for children with familial history of atopy

         prospective birth cohort study of 498 children with
          parental history of allergy or asthma followed
          prospectively for first year of life



Pediatrics 1999 Sep;104(3):495 Level 2b
  Acute Otitis Media Risk Factors.
      Associated with 2 or more doctor-diagnosed
       ear infections (odds ratio [OR] 2.4, 95%
       confidence interval [CI] 1.7-3.6)

      For children attending day care independent
       predictors of 2 or more doctor-diagnosed ear
       infections included
           exposure to pets in day care
           presence of rug or carpet in area where child slept
            in day care
           nonresidential setting for day care

Pediatrics 1999 Sep;104(3):495 Level 2b
 Acute Otitis Media Risk Factors
     Passive Smoking
           625 Children Calgary first graders
           Middle ear disease
                 2 or more household smokers (crude odds ratio) [OR],
                  1.85; 95% confidence interval [CI], 1.15-2.97
                 10 or more cigarettes smoked by the mother per day
                  (crude OR, 1.68; 95% CI, 1.12-2.52)
                 10 or more cigarettes smoked in total in the household
                  per day (crude OR, 1.40; 95% CI, 0.98-2.00) during the
                  first 3 years of life



Arch Pediatric Adolescent Med. 1998 Feb;152(2):127 Level 2c
            Acute Otitis Media
                 History
                      Poor predictive value
                      Studies are not good


                 Statistics
                      LR+ greater than 5 good
                      LR- less than 0.5 good
                      Specificity to rule in
                      Sensitivity to rule out

Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633
                Acute Otitis Media
               Symptom                         LR+        LR-       Sensitivity Specificity
               Ear rubbing                    3.20 0.670                 42%              87%
               Ear pain                       3.00 0.560                 54%              82%
               Excessive crying 1.80 0.650                               55%              69%
               Rhinitis                       1.30 0.580                 75%              43%
               Restless sleeping 1.30 0.710                              64%              51%
               Poor appetite                  1.10 0.970                 36%              66%
               Vomiting                       1.00 1.000                 11%              89%



Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633
             Acute Otitis Media
   Physical Findings
       Based on prospective study of 8,859 ear-related visits
        among children 0.5-2.5 years with acute symptoms
            myringotomy performed if middle ear effusion suspected on exam
            51.5% had acute otitis media (i.e. middle ear effusion confirmed on
             myringotomy)
       Color not particularly helpful but cloudy membrane
        predictive
            red color was not highly predictive
            cloudy tympanic membrane had 80-96% positive predictive value
            normal color dramatically reduces likelihood of AOM (2-5%
             probability of middle ear effusion if normal color)


Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1a
             Acute Otitis Media
                  Physical Continued
                        Position helpful if clearly bulging
                              bulging tympanic membrane had 89-96%
                               positive predictive value
                              retracted tympanic membrane had 47-50%
                               positive predictive value
                              normal position had 22-32% probability of AOM



Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1a
Acute Otitis Media
    Mobility helpful if distinctly impaired or
     clearly normal
         distinctly impaired mobility had 78-94%
          positive predictive value
         slightly impaired mobility had 33-60% positive
          predictive value
         normal mobility dramatically reduces likelihood
          of AOM (2-5% probability of middle ear
          effusion if normal mobility)
Acute Otitis Media
                                 Positive Likelihood
Test Name
                                   Ratio
TM position: bulging                      51.00
TM color: cloudy                          34.00
TM mobility: distinctly
                                          31.00
  impaired
TM color: distinctly red                   8.40
TM mobility: slightly impaired             4.00
TM position: retracted                     3.50
TM color: slightly red                     1.40
TM position: normal                        0.50
TM color: normal                           0.20
TM mobility: normal                        0.20
Acute Otitis Media
   Type A pattern is
    normal
   Type B pattern is
    consistent with MEE
   Type C is seen with
    retracted TM
        Acute Otitis Media Prognosis
             Spontaneous resolution is the norm
             81% spontaneously resolve (1)
             5000 children with otitis
                  >90% resolved with supportive care
                  2.7% had a severe course (required
                   antibiotics or myringotomy at 5 days)


1)   Arch Pediatr Adolesc Med 2001;155(10):1097Level 1a
       Acute Otitis Media Prognosis
          Recurrent otitis media no long term
           consequences
              usually spontaneous recovery
              study of 222 children with recurrent otitis media
               who received no prophylaxis
                   4% developed chronic otitis media with effusion
                   12% continued having recurrent episodes
                   most significant risk factor for continued recurrence was
                    age < 16 months (1)


1) Pediatrics 5 May 2004 113:1452 Level 1a
              Acute Otitis Media Prognosis
                      Persistent effusion
                            Watchful Waiting recommended in children
                             without the following:
                                  Permanent hearing loss independent of OME
                                  Suspected or diagnosed speech and language delay
                                   or disorder
                                  Autism-spectrum disorder and other pervasive
                                   developmental disorders syndromes (e.g., Down)
                                  Craniofacial disorders that include cognitive, speech,
                                   and language delays
                                  Blindness or uncorrectable visual impairment
                                  Cleft palate with or without associated syndrome
                                  Developmental delay
Pediatrics 2004 113:5; 1412-1429 Level 1a
        Acute Otitis Media Prognosis
                 Persistent effusion
                      Change from B to non-B tympanogram
                       favorable
                      25% of OME of unknown duration resolves in 3
                       months
                      Warn parents of decreased hearing while
                       effusion present
                      Recheck every three months



Pediatrics 5 May 2004 113:5; 1412-1429 Level 1a
    Acute Otitis Media Treatment
        Treat Pain
            Acetaminophen and ibuprofen (1)
            219 children treated with cefaclor
             evaluated pain at 2 days
                 Ibuprofen 7% with pain NNT 5
                 Acetaminophen 10% with pain NNT 6
                 Placebo 25%



1) Fundam Clin Pharmacol. 1996;10(4):387 Level 1c
           Acute Otitis Media Treatment
              Topical analgesics effective              1

                    Systematic review of 4 RCT
                         Anesthetic ear drops have significant reduction
                          in pain at 30 minutes
                         Naturopathic herbals had similar results at 30
                          minutes
                         Longer duration of relief with naturopathic
                          drops


1- Cochrane Library 2006 Issue 3:CD005657 Level 1a
Acute Otitis Media Treatment
   Initial treatment options are observation or antibiotics
       for children < 6 months old, antibiotics recommended
       for children 6 months to 2 years old observation option
        recommended only if all of the following are present
            otherwise healthy child
            uncertain diagnosis
            non-severe illness
            follow-up can be ensured so antibiotics can be started if
             symptoms persist or worsen

       antibiotics recommended if certain diagnosis of AOM, severe
        illness, or follow-up cannot be ensured
         Acute Otitis Media Treatment
   For children > 2 years old
        Observation option recommended only if the following
         are present
             otherwise healthy child
             uncertain diagnosis OR non-severe illness
             follow-up can be ensured so antibiotics can be started if
              symptoms persist or worsen


        Antibiotics recommended if certain diagnosis of AOM
         and severe illness, or follow-up cannot be ensured

Am Fam Physician 2004 Jun 1;69(11):2713 Level 1a
Acute Otitis Media Treatment
   No improvement in 48-72 hours
       Confirm the diagnosis
       If AOM certain then begin antibiotics if not
        already started
       Change antibiotics if already started
Acute Otitis Media Treatment
   Wait and see approach is reasonable
   283 children 6 month to 12 years with acute
    otitis seen in ER
   At 4-6 days
       Wait and see group not to fill Rx unless not better
        or if worse in 48 hours
       Everyone got ibuprofen, otic drops and antibiotic
        Rx
       94% follow up
       62% of wait and see did not fill RX 13% in
        standard care (NNT 2)
          Acute Otitis Media Treatment
              Wait and See continued
                   No difference in otalgia severity or duration
                   No difference in fever
                   No difference in unscheduled follow up
                    appointment
                   8% of wait and see vs. 23% of standard care had
                    diarrhea (NNH 7)
              Data persisted to 11-14 days and 30-40 days

JAMA 2006 Sep 13;296(10):1235 Level 1b
   Acute Otitis Media Treatment
      Antibiotics
          CDC guidelines for management and
           surveillance of acute otitis media in era of
           pneumococcal resistance
               You must know your community




1) Pediatrics 2004;113(5):1452 Level 1a
        Acute Otitis Media Treatment
                Amoxicillin 80-90 mg/kg/day divided TID
                 for 10 days
                     Failure at 3 days switch to one of the following
                     cefuroxime axetil (Ceftin) 15 mg/kg BID for 10
                      days
                     amoxicillin-clavulanate (Augmentin) Augmentin
                      45 mg/kg/day divided BID or 40 mg/kg/day
                      divided TID, both for 10 days
                     ceftriaxone (Rocephin) IM 50mg/kg for 3 days


1) Pediatric Infect Dis J. 1999 Jan;18(1):1 Level 1a
          Acute Otitis Media Treatment
              Penicillin Sensitive patients
                   Not Type I reaction (no urticaria or
                    anaphylaxis) (1)
                         Cefdinir (Omnicef) 14 mg/kg divided once daily
                          or BID for 5 days (BID dosing) or 10 days
                          (once daily dosing) slightly better taste (2)
                         Cefpodoxime (Vantin) 10 mg/kg once daily for
                          10 days or divided BID for 5 days
                         Cefuroxime (Ceftin or Zinacef) 30 mg/kg
                          divided BID for 10 days
                         Ceftriaxone (Rocephin) 50mg/kg IM once
1) Pediatrics 5 May 2004;113(5):1452 Level 1a
2) Pediatrics 2005 Apr;115(4):1048 Level 1a
   Acute Otitis Media Treatment
       Penicillin Sensitive Patients
            Type I reaction
                  Azithromycin (Zithromax) 10 mg/kg day one then 5
                   mg/kg days 2-5
                  Clarithromycin (Biaxin) 15 mg/day divided BID for 10
                   days
                  Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg daily of
                   erythromycin divided TID to QID for 10 days
                  Sulfamethoxazole-trimethoprim (Bactrim or Septra) 6-10
                   mg/kg daily of trimethoprim divided BID for 10 days



Pediatrics 5 May 2004;113(5):1452 Level 1a
     Acute Otitis Media Reality
        Shorter therapy 5 days is likely as beneficial
         as longer therapy (1)
        Early treatment with antibiotics may lead to
         increased resistance (2)
        Side effects are as common as benefit
            NNT 15-17 at 1 week
            NNH 17 at one week
        Delayed antibiotics result in decreased use
         and decreased likelihood of asking for
         antibiotics in the future (3)
1)   JAMA. 1998 Jun 3;279(21):1736 Level 1a
2)   J Infect Dis. 2001 Mar 15;183(6):880 Level 4
3)   BMJ 2001 Feb 10;322:336 Level 1c
Acute Otitis Media
   Guideline Review
       Pediatrics 2004 May;113(5):1451
       Summary can be found in Am Fam
        Physician 2004 Jun 1;69(11):2713
       editorial can be found in Am Fam Physician
        2004 Jun 1;69(11):2537
       commentary can be found in Pediatrics
        2004 Sep;114(3):898
       commentary can be found in Pediatrics
        2005 Feb;115(2):513
 Serous Otitis Media




www.pedisurg.com/ PtEducENT/Default.htm
     Serous Otitis Media Causes
         Causes
               Overgrowth of lymphoid tissue in the
                nasopharynx
               Chronic sinus infection
               Allergies of nose and nasopharynx
               Gastric reflux implicated
                     Pepsin seen in MEE 45 of 54 children with SOM
                      (1)

                     Pepsin seen in MEE 59 of 65 children with SOM
                      (2)
1)   Lancet 2002 Feb 9;359(9305):493 Level 4
2)   Laryngoscope. 2002 Nov;112(11):1930 Level 4
                Serous Otitis Media Complications
                    Permanent hearing loss (?) (5)
                    Tympanosclerosis
                    Fibrosis of middle ear space
                    Balance problems (1)
                    Minor language deficits (+/-) (2)
                    No association with attention or behavior in
                     first 6 years of life (3)
                    Possible behavior problems in teens (4)
1)   Pediatrics. 1997 Mar;99(3):334 Level 4
2)   Pediatrics. 2000 May;105(5):1119 Level 2c   4) Arch Dis Child. 2001 Aug;85(2):91 Level 1b
3)   Pediatrics. 2001 May;107(5):1037 Level 1b   5) Pediatrics. 2000 Sep;106(3):E42 Level 1c
Serous Otitis Media Physical
   Physical examination
       Pearly gray
       Minimal dullness
       Minimal retraction
       Presence of effusion
     Serous Otitis Media Tests
        Key tests
            Pneumo-otoscopy with limited movement
             (1)

                   Sensitivity of 94% (95% CI: 92%-96%)
                   Specificity of 80% (95% CI: 75%-86%)
            Tympanogram B-curve                      (2)

                   81% sensitivity
                   56% specificity


1)   Pediatrics. 2003 Dec;112(6 Pt 1):1379 Level 1a
2)   Clin Otolaryngol. 2003 Jun;28(3):183 Leve 1c
      Serous Otitis Media Prognosis
           High rate of spontaneous resolution                      (1)

                Most resolve in 3 months
           Meta-analysis 11 trials                    (2)

                No significant hearing loss
                No speech/language delay
           Tubes have consequences                           (3)

                140 children followed 8 years
                Sequela higher at 3-5 years
                       47%   for   retraction pocket
                       67%   for   tympanic membrane atrophy
                       40%   for   myringosclerosis
                       23%   for   hearing loss
1)   J Fam Pract 2000 Jul;49(7):605,612 Level 1a
2)   Pediatrics 2004 March; 113(3): e238 Level 1a
3)   Arch Otolaryngol Head Neck Surg. 2003 May;129(5):517 level 1b
        Serous Otitis Media Treatment
            Medications
                  Antibiotics not beneficial              (1)

                        Most rigorous meta-analysis find no benefit
                         long-term
                        Some short-term benefit may exist
            Steroids
                  Nasal steroids no evidence of benefit         (2)

            Systemic steroids no difference long
             term (3)
1)   J Fam Pract. 2003 Apr;52(4):321 FPIN network answer
2)   Cochrane Library 2006 Issue 3:CD001935 Level 1a
3)   Pediatrics. 2002 Dec;110(6):1071 Level 2b
          Serous Otitis Media Treatment
               Antihistamines or decongestants are not
                beneficial
                    Cochrane review of trials of limited quality
                    Systematic review of 14 RCT
                    No benefit found for any outcome
                    Antihistamines were associated with side
                     effects (NNH 8)

Cochrane Library 2006 Issue 4:CD003423 Level 2a
     Serous Otitis Media Treatment
        Surgery no clear evidence of benefit
            RCT of a birth cohort that developed MEE (1)
                  Randomized to early tube placement or delay of 6
                   months (unilateral MEE) to 9 months (bilateral MEE)
                  Delayed group had better outcomes cognition, language
                   (not significant) at age 3
                  Follow up through 11 years of age no developmental or
                   speech delay 3
            Reduced time with MEE but no change in
             language or hearing (2)
            No change in quality of life

1)   N Engl J Med. 2001 Apr 19;344(16):1179 Level 1b
2)   Cochrane Library 2005 Issue 1:CD001801 Level 1a
3)   N Engl J Med 2007 Jan18:356(3):248 Level 1b
        Serous Otitis Media Treatment
   Surgery no clear evidence of benefit
       Cohort 30,099 children born in the Netherlands
             Routine hearing screening at age 9 months
             1,081 who failed 3 successive hearing screens were referred to
              ENT surgeon
             386 found to have persistent bilateral otitis media with effusion
              for 4-6 months
       187 children (mean age 19.5 months) were randomized
        to ventilation tubes vs. watchful waiting and followed for
        1 year with language tests
       Ventilation tubes reduced diagnoses of bilateral otitis
        media with effusion at all measurements (NNT 2-4),
       No differences in language development
Pediatrics 2000 Sep;106(3):e42 Level 1c
   Serous Otitis Media Treatment
       Post-tube precautions
             unrandomized trial in 533 children who underwent
              tympanostomy tube placement
             parents self-selected into 1 of 3 "treatments" to prevent
              complications of swimming
                   no additional precautions
                   antibiotic drops following swimming
                   ear molds worn during swimming
                   control group consisted of children who never went swimming
                   all were given precautions against deep water swimming (>
                    180 cm), diving and soapy water in ears during bathing
             no benefit was noted from antibiotic ear drops or ear plugs


Arch Otolaryngol Head Neck Surg. 1996 Mar;122(3):276 Level 2b
Strep Pharyngitis




         http://web.indstate.edu/thcme/micro/strep/sld009.htm
  Strep Pharyngitis Basics
       Bacteria Streptococcus pyogenes
            AKA Group A beta-hemolytic streptococcus
             (GABHS)
            More than 80 sero-types based on M protein
            Transmission
                   Person-person
                   Aerosol
                   Water
                   NOT household pets (1)
            Incubation period 2-4 days

Pediatric Infect Dis J 1995 May;14;372
     Strep Pharyngitis Risk Factors
         More common during school year
         Crowded living situation
         Exposure to GABHS
         Youth
         Immunosuppression
         Smoking
         Excessive alcohol consumption
         Diabetes mellitus
         Recent illness
Griffin's 5 Minute Clinical Consult from InfoRetriever Level 5
     Strep Pharyngitis
     Complications
         Acute Rheumatic Fever                    (1)
               Develops in 1-3% children with GABHS
               Only throat infections not skin
               Common in developing nations (2)
                     30 million children in the developing world have heart disease
                      due to rheumatic fever
                     70% of whom will die prematurely at average age of 35
         Acute Glomerulonephritis
               Less common than rheumatic fever
               Most patients recover
         Tonsillitis
         Peritonsillar Abscess

1)   Pediatrician. 1986;13(4):180 Level 3
2)   Tropical Doctor 1999 Jul;29(3):129 Level 5
Strep Pharyngitis History
   Abrupt onset of symptoms
   Fever may last 4-5 days
   Constitutional symptoms
           Fever and chills
           Myalgias
           Headache
           Nausea and vomiting
   Unlikely to have runny nose, cough, conjunctivitis,
    hoarseness, diarrhea
   Exposure to strep throat infection in previous 2
    weeks associated with increased likelihood of strep
    throat
           Strep Pharyngitis Therapy
               Reasons patients visit the physician for sore
                throat
                     298 patient >12 year old in Belgium
                     Most frequent reasons for visit
                           Establish cause (85.5%)
                           Pain relief (84.5%)
                           Information on disease course (82.7%)
                           Seriousness of problem (76.4%)
                           Time to recovery (75.7%)
                           Education on treatments (73.2%)
                           Desire antibiotic (37.6%)
Ann Fam Med 2006 Nov-Dec;4(6):494 Level 3c
 Strep Pharyngitis Tests
     Rapid Strep Tests
         Results available in 5-10 minutes
         76-87% sensitivity
         > 95% specificity depending on specific test kit
          used
         Genzyme's OSOM Ultra Strep A test
              92.6% sensitivity
              92.8% specificity
         Biostar's Strep A OIA Max Test
              75.5% sensitivity
              97.1% specificity


Pediatric Infect Dis J 2002 Oct;21(10):922 Level 1c
         Strep Pharyngitis Tests
             Rapid strep test
                   15% false positive rate in adults (1)
                   Study of 522 adults with acute pharyngitis and/or
                    tonsillitis who had positive rapid antigen detection
                    test results
                   77 (15%) had negative cultures for group A
                    streptococci
             Low sensitivity
                   If sensitivity below 90% consider backup culture
                    (3)

                   Physicians should validate the sensitivity of their
                    own Rapid strep tests
1)   J Infect Dis. 2001 Apr 1;183(7):1135 Level 2b
2)   Br J Gen Pract 1998 Feb;48;959 Level 2b
3)   Pediatrics 2004 Apr;113(4):924
   Strep Pharyngitis Rules
       Canadian Approach
             One Point Each
                   Temp >38 C
                   No Cough
                   Tender anterior lymph nodes
                   Tonsillar swelling or exudate
                   Age 3-14 years
             No Points
                   Age 15-44 years
             Subtract One point
                   Age >44 years
CMAJ. 1998 Jan 13;158(1):75 Level 1c
Strep Pharyngitis Rules
Score   Overall (%)    Cx (-)      Cx(+)     LR(+)


 0      160 (31.8)    156(97.5)    4(2.5)    0.14

 1      138(27.4)     131(94.9)    7(5.1)    0.32


 2       98(19.5)     87(88.8)    11(11.2)   0.84


 3       54(10.7)     39(72.2)    15(27.8)   2.49


 4       53(10.5)     25(47.2)    28(52.8)   6.43
       Strep Pharyngitis Strategies
           Canadian Scoring System
           Authors' recommendations
                 withhold antibiotics and culture if score 0-1
                 culture if score 2-3
                 empiric antibiotics if score 4-5




CMAJ. 2000 Oct 3;163(7):811 Level 1a
   Strep Pharyngitis Strategies
       Study of 621 patients seen by 97 Canadian
        family physicians
             600 had throat culture of which 17% were positive
                   risk of strep throat was 1% if score 0 or -1
                   10% if 1
                   17% if 2
                   35% if 3
                   51% if 4 or 5
             following clinical rule would have reduced
              unnecessary antibiotic prescriptions by 64% and
              use of throat cultures by 35%

CMAJ. 2000 Oct 3;163(7):811 Level 1a
   Strep Pharyngitis Rules
       Centor clinical prediction rule validated in 3
        adult populations
            1 point if tonsillar exudate
            1 point if swollen tender anterior cervical nodes
            1 point if absence of cough
            1 point of history of fever
            0-1 points suggests very low risk
            3-4 points suggests increased risk for strep throat


JAMA 2000 Dec 13;284(22);2912 Level 1a
       Strep Pharyngitis Strategies
           CDC evidence-based guidelines
           Adults (1)
                 4 empiric treatment
                 3 empiric treatment or rapid antigen
                  testing with treatment only if positive
                 2 rapid antigen testing (treatment only if
                  positive) or no testing or antibiotic
                  treatment
                 1 or 0 no testing or antibiotic treatment
1) Ann Intern Med 2001 Mar 20;134(6):479 Level 1a
Strep Pharyngitis Therapy
   Comfort Medications
       systemic analgesics and antipyretics - such as
        acetaminophen (Tylenol) or NSAIDs (e.g.,
        ibuprofen [Motrin])
       topical analgesics (e.g., nonprescription throat
        sprays) and anesthetics (e.g., viscous lidocaine
        2%)
       warm salt water gargles
       throat lozenges, hard candy or frozen desserts
       soft foods or cold thick liquids (e.g., ice cream,
        nectars, pudding)
       humidifier
  Strep Pharyngitis Therapy
     Antibiotics
         Penicillin is the gold standard for
          prevention of Rheumatic Fever
          (Historically)
         Benzathine penicillin G 1.2 million U (600-
          900,000 U if age < 12) IM once
         Penicillin V 500 mg PO tid for 10 days
              In children, penicillin VK 25-50 mg/kg/day
               divided bid to qid
CDC Recommendations
    Strep Pharyngitis Therapy
        Amoxicillin
            in children, 20-50 mg/kg/day divided bid to tid
            short-course amoxicillin (1 g PO bid for 6 days) as
             effective as penicillin 500 mg tid for 10 days in
             trial of 338 patients > 15 years old (1)
                 clinical cure rate was 96.4% vs. 96.5% at 72 hours after
                  treatment and 93.5% vs. 96.3% at 1 month
                 10 vs. 6 recurrences
                 throat pain resolved more quickly on amoxicillin
                 3% vs. 5.2% adverse effects

1) Scand J Infect Dis. 1996;28(5):497 Level 1c
  Strep Pharyngitis Therapy
       Amoxicillin
            once-daily amoxicillin 750 mg PO qd for 10 days
                   No significant difference in clinical or bacteriologic responses at
                    18-24-hour follow-up visit

                   5% vs. 11% bacteriologic treatment failures
                          at subsequent follow-up visits over 4 days through 3 weeks, 16%
                           vs. 21% had positive throat cultures
                          many were considered a "new acquisition" since the organism was
                           a different strain of group A beta-hemolytic streptococci;

                   among 79 patients in amoxicillin group
                          2 had macular rash
                          3 had diarrhea
                          3 had abdominal pain



Pediatrics. 1999 Jan;103(1):47 Level 1c
  Strep Pharyngitis Therapy
      Oral Cephalosporins
            Systematic review and meta-analysis of 35
             randomized trials with 7,125 children
                  Most trials were low quality
                         59% with Jahad Score 0-2
                         Jahad score rates quality of study
                         0 (low) to 5 (high)
                  Bacteriologic cure rates (92.6% vs. 80.6%, NNT 8)
                  Clinical cure rates (93.6% vs. 85.8%, NNT 13)
                  Differences in clinical cure occurred among studies of
                   cefuroxime and loracarbef
Pediatrics 2004 Apr;113(4):866 Level 1a
    Strep Pharyngitis Therapy
        Clarithromycin for 5 days as effective as
         penicillin for 10 days
                    349 patients aged 12-40 with acute strep
                    Randomized to clarithromycin modified-release
                     500 mg once daily for 5 days vs. penicillin 590
                     mg tid for 10 days
                    No significant differences in clinical cure rates
                     (88% vs. 92%) or eradication rates (83% vs.
                     84%)
                    Open Label Phase III Study

J Antimicrob Chemother 2002 Feb;49(2):337 Level 2c
     Strep Pharyngitis Therapy
          Azithromycin
                      60 mg/kg total dose more effective than lower
                       doses
                             20 mg/kg/day for 3 days
                             12 mg/kg/day for 5 days
                      Systematic review of 19 low to poor quality
                       trials
                             NNT 7 for 60 mg/kg dose
                             NNH 6 for 30 mg/kg dose


Clin Infect Dis 2005 Jun 15;40(12):1748 Level 2c
     Strep Pharyngitis Therapy
        Dexamethasone 0.6 mg/kg up to 10 mg
         PO or IM in single dose associated with
         faster pain relief (median 4 hours) and
         may reduce return visits;
               118 patients >15 years old presenting to emergency
                department
               Randomized to dexamethasone 10 mg PO vs.
                dexamethasone 10 mg IM vs. double placebo
               All patients given penicillin VK 500 mg (erythromycin 333
                mg if penicillin-allergic) PO tid for 10 days and 6 doses of
                acetaminophen for 24 hours
        Pain measured on 0-10 scale

Laryngoscope 2002 Jan;112(1):87          Level 2b
Strep Pharyngitis Therapy
   Median reduction in pain scores
       IM dexamethasone
            12 hours -4
            24 hours -5
            19% resolution at 24 hours
       PO dexamethasone
            12 hours -3
            24 hours -4
            20% resolution pain at 24 hours
       Placebo
            12 hours -2
            24 hours -4
            3% resolution of pain at 24 hours
Strep Pharyngitis Therapy
   Time to onset of pain relief was
       5.8 hours with IM dexamethasone
       6 hours with PO dexamethasone
       10.1 hours with placebo (p = 0.029)

   Return Visits within 5 days
       No patients receiving IM dexamethasone
       7% receiving PO dexamethasone
       16% receiving placebo returned to emergency
        department for sore throat within 5 days (p =
        0.23)
Strep Pharyngitis Guidelines
   Sore Throat Encounter Form
    http://www.aafp.org/afp/20030901/poc
    form.html
       American Family Physician 2003
        Sep1;68(5):938

				
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