Published online December 1, 2006
PEDIATRICS Vol. 118 No. 6 December 2006, pp. e1607-e1611 (doi:10.1542/peds.2006-1025)
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ARTICLE

Pharyngitis in Low-Resources Settings: A Pragmatic Clinical Approach to Reduce Unnecessary Antibiotic Use

Pierre Robert Smeesters, MDa,b, Dioclécio Campos, Jr, MD, PhDa, Laurence Van Melderen, PhDc, Eurico de Aguiar, MDd, Jean Vanderpas, MD, PhDe and Anne Vergison, MDb,e

a Serviço de Pediatria, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
b Département des Maladies Infectieuses, Hôpital Universitaire des Enfants Reine Fabiola
c Laboratoire de Génétique des Procaryotes, Institut de Biologie et de Médecine Moléculaire
e Unité d'épidémiologie et d'hygiène hospitalière, Hôpital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
d Serviço de Microbiologia, Hospital Regional da Asa Sul, Brasília, Brazil

OBJECTIVE. Existing scoring systems for the diagnosis of group A streptococcus pharyngitis are insensitive or inapplicable in low-resources settings. Bacterial cultures and rapid tests can allow for antibiotic prescription abstention in high-income regions. These techniques are not feasible in many low-resources settings, and antibiotics often are prescribed for any pharyngitis episode. However, judicious antibiotics prescription in the community also is of concern in low-income countries. The objective of this study was to develop a clinical decision rule that allows for the reduction of empirical antibiotic therapy for children with pharyngitis in low-resources settings by identifying non–group A streptococcus pharyngitis.

PATIENTS AND METHODS. We prospectively included children with pharyngitis in 3 public hospitals of Brazil during 9 months in 2004. We filled out clinical questionnaires and performed throat swabs. Bilateral {chi}2 (2-tailed test) and multivariate analysis were used to determine score categories. The outcome measures were sensitivity, specificity, positive likelihood ratio, and posttest probability of non–group A streptococcus infection with the clinical approach as compared with throat culture.

RESULTS. A total of 163 of the 220 children had non–group A streptococcus pharyngitis (negative culture). We established a 3-questions decision rule (age and viral and bacterial signs) with 3 possible answers. The use of this score would prevent 41% to 55% of unnecessary antimicrobial prescriptions. The specificity of the score for non–group A streptococcus pharyngitis was >84%.

CONCLUSION. Such a clinical decision rule could be helpful to reduce significantly unnecessary antibiotic prescriptions for pharyngitis in children in low-resources settings.

Key Words: pharyngitis • practice guidelines • antibiotic use • developing countries

Abbreviations: GAS—group A streptococcus

Accepted Jul 11, 2006.




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