Streptoccocal Pharyngitis and Appropriate use of Antibiotics

1. Streptoccocal Pharyngitis and Appropriate use of Antibiotics Natalie Darro DO, PGY 1 Educator Advocacy October, 2012

2. What am I advocating for… UNSOM Pediatricians and Pediatric residents influencing the development of antibiotic resistance in our community Controlled use of antibiotics, especially during cold and flu season Strong communication skills with our patients Use of evidence based medicine in our practices. Ultimately research in the community regarding usefulness of antibiotic education

3. Presentation Objectives • What we as physicians need to know • IDSA Guidelines Strep Pharyngitis • What our patients need to know • Practical application of material for communication in a clinical setting • Resources for clinical settings

4. Streptococcal Pharyngitis • Causitive organism is Streptoccocospyogenes • GAS causes the widest range of syndromes of any bacterium • GAS accounts for 15-30% of pharyngitis in children • Ages 5-11 have highest incidence • Major rationale for accurate DX and TX is prevention of Acute rheumatic (Scarlet) fever (ARF) and Rheumatic Heart Disease (RHD), Post Streptococcal Glomerular nephritis, and suppurative complications (peritonsillar abscess)

5. Critical importance of accurate diagnosis Strep throat is generally a self limited 3-5 day illness Signs and symptoms of GAS and nonstreptoccalpharyngitis overlap broadly, accurate DX on clinical grounds alone is impossible With exception of very rare pharyngeal infections (egCorynebacteriumdiphtheriae, Neisseriagonorrhoeae) antibiotics are of no proven benefit as treatment for acute pharyngitis It is extremely important to exclude GAS pharyngitis to prevent overuse of ABX Inappropriate abx use for URIs including pharyngitis has been a major contributor to the development of antimicrobial resistance

6. Scarlet fever exanthem: erythematous, diffuse, sandpapery, punctuated by “Pastia lines” rash concentrated in flexor skin creases, blanches with pressure, spares circumoral. Its important to test only those that meet clinical suspicion as patients can be Strep carriers with concurrent viral pharyngitis, prompting inappropriate use of antimicrobials

7. AAP Clinical Practice Guidelines • Patients who have a constellation of signs and symptoms suggestive of GAS pharyngitis should be tested for infections: • Posterior pharynx swab • RADT • Culture • <3 yo infrequently present with GAS pharyngitis, almost never develop ARF, documentation and treatment is optional • Relying solely on clinical suspicion is discouraged • RADT : Rapid Antigen Detection Testing • High Specificity 95-98% • Sensitivity 70-90% • Positive RADT  no culture • Negative RADT  culture • Throat culture is gold standard: 90-95% sensitive • Optimally: rub both tonsils and posterior pharyngeal wall • Innoculate on sheep blood agar 37 C x 24 hrs, then 24 hrs room temp  small gray-white colonies with zone of beta hemolysis

8. IDSA 2012 Guidelines • How should the diagnosis of GAS pharyngitis be established? • Who should undergo testing for GAS? • What are the treatment recommendations for patients with Dx of GAS pharyngitis • Should adjunctive therapy with NSAIDS, acetaminophen, or aspirin be used in treatment • Is the patient with frequent recurrent episodes of GAS likely to be a chronic pharyngeal carrier?

9. How should diagnosis GAS pharyngitis be established? • Throat swab with RADT (except with overt viral features) • Throat culture for negative RADT, not for positive RADT • Do not have to culture adult negative RADT • Anti-streptococcal antibody titers are NOT recommended • Who should undergo testing for GAS pharyngitis • Testing not recommended: acute pharyngitis with signs/symptoms strongly suggest viral • Not recommended: Children < 3 yo unless RF of close contact diagnosed • Utilize demographic and symptoms to determine yield of testing, clinical scoring can also be helpful • Follow up post treatment throat cultures is not recommended, may consider with suspicion of carrier status, or resistant Strep species • Empiric treatment or diagnostic testing of asymptomatic household contacts is not recommended

10. What are the treatment recommendations for patients diagnosed with GAS pharyngitis? • Appropriate antibiotic, appropriate dose x 10 days to eradicate the organism from the pharynx: • PCN or amoxicillin : narrow spectrum, low SE, low COST!!! Tx of choice • PCN allergic: 1st gen cephalosporin x 10 days, clindamycinx 10 days or azithromycinx 5 days • Should adjunctive NSAID therapy by given? • Analgesic/antipyretic agent such as tylenol or NSAID is appropriate, aspirin should not be given to children, corticosteroids are not recommended • Is the patient with frequent recurrent episodes of GAS pharyngitis likely to be a chronic carrier? • >1 laboratory confirmed GAS pharyngitis in close intervals: likely GAS carrier with repeated viral infections • Do not generally require antibiotics: unlikely to spread GAS, unlikely to develop complications such as ARF • Do not recommend tonsillectomy solely to reduce frequency of GAS pharyngitis

11. So we know what we as physicians need to know…. What do our patient’s need to know??

12. Patient’s need to know…. That we care about them/their condition That we are trustworthy Education on their level about their condition What are emergency signs/symptoms What the treatments are

13. Patient’s need to know… • What pharyngitis/URI is • What the difference is between causes • Viral vs. bacterial • What we are using to support our clinical decision making regarding their symptoms and visit.

14. Communication with our Patient Population Did you know that : Good patient communication having therapeutic effect that improves patient health as quantifiably as drugs has been validated by controlled studies?

15. What barriers exist to communication with our patients? • Medical information and support groups found on the Internet, while potentially a great asset in edu- cating and motivating patients toward better health, have many physicians questioning their traditional role as most trusted counselors. • Despite evidence indicating that the average length of the patient- physician encounter has not changed significantly in recent years, specific survey data indicate a correlation between patient participation in capitated health plans and shorter office visits. Further, hurdles arising from linguistic and cultural differences, already abundant, will only increase in coming years

16. How do we combat those barriers? the physician makes nuanced choices regarding the words, questions, silences, tones, and facial expressions he or she chooses • During the typical 15- or 20-minute patient-physician encounter: • These choices either enhance or detract from the overall level of excellence of the physician’s delivery of care. Traps to avoid!!!

17. How do we combat these barriers? • Assess what the patient already knows • Assess what the patient wants to know • Be empathetic • Slow down • Keep it simple • Tell the truth • Be hopeful • Watch the patient’s body and face • Be prepared for a reaction • Be creative • Utilize your resources!!!

18. Ok Natalie…if you’re so smart how do you explain the difference between a virus and bacteria?Isn’t it an innately scientific concept learned by physicians over 8 years of education?

20. Ha ha ha! Awesome pictures Natalie! How about resources?

24. In conclusion…. • As we enter flu season it is part of our responsibility to treat pharyngitis appropriately • We need to recognize that antibiotic resistance is a serious problem that we play an important role in • I’m advocating for appropriate use of antibiotics this flu season and hopefully better overall communication and relationships with our patients!!! • How this presentation helps you: • Review of IDSA and AAP guidelines • Review of communication pitfalls and strategies • Resources for our clinics to facilitate communication during this cold and flu season! Thank you!!!!

25. References • Shulman et al. “Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America”; CID advance access, September 9th, 2012 • Shulman ST, Jaggi P, “Group A Streptococcal Infections”; Pediatrics in Review, Pediatr. Rev. 2006;27;99-105 • Traveline JM, Ruchinskas R, D’Alonzo GE. “Patient-Physician Communication: Why and How”; Journal of American Osteopathic Association, Clinical Practice; Vol 105; No 1; January 2005 • www.aware.md ; California Medical Association 2013, AWARE; Alliance Working for Antibiotic Resistance Education; Resources for Healthcare Professionals