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Paper 3
Published in Aalia Khan, Ramsey Jabbour, Almas Rehman, nMRCGP Applied Knowledge Test Study Guide, 2021
Aalia Khan, Ramsey Jabbour, Almas Rehman
Most sore throats are self-limiting whether due to viral or bacterial infection. If required, phenoxymethylpenicillin is the first-line treatment of choice. It is important not to prescribe amoxicillin, because if the tonsillitis is a presentation of glandular fever, amoxicillin will cause a maculopapular rash. If three or four of the following Centor criteria are present, there is a 40–60% chance of the patient suffering from Group A ß-haemolytic Streptococcus and antibiotics may be beneficial. These include: tonsillar exudate; tender anterior cervical lymph nodes; absence of cough; and history of fever. www.gpnotebook.co.uk
Diagnostic Approach to Rash and Fever in the Critical Care Unit
Published in Cheston B. Cunha, Burke A. Cunha, Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine, 2020
Lee S. Engel, Charles V. Sanders, Fred A. Lopez
The rash of scarlet fever starts on the neck, chest, armpits, and groin and spreads to the arms and legs [10,178]. The rash is erythematous and diffuse and blanches with pressure. There are numerous papular areas in the rash that produce a sandpaper-type quality. On the antecubital fossa and axillary folds, the rash has a linear petechial character referred to as Pastia’s lines [178]. The rash varies in intensity but usually fades in 4‒5 days. Diffuse desquamation occurs after the rash fades [178]. Diagnosis of scarlet fever can usually be made on a clinical basis. The Centor criteria can aid the diagnosis of Group A streptococcal pharyngitis [179]. Confirmation of the diagnosis is supported by isolation of Group A streptococci from the pharynx and serology [159]. Complications of scarlet fever include peritonsillar and retropharyngeal abscesses, glomerulonephritis, pneumonia, endocarditis, and meningitis [177].
Diagnostic strategy
Published in Caroline J Rodgers, Richard Harrington, Helping Hands: An Introduction to Diagnostic Strategy and Clinical Reasoning, 2019
Caroline J Rodgers, Richard Harrington
Clinical prediction rules use predictors from a patient’s history, examination and investigations to help a clinician decide, for example, the following: Whether a patient has a certain diagnosis (e.g. the Wells score for prediction of deep vein thrombosis [DVT]).Is at risk of a diagnosis (e.g. the ABCD2 rule for risk of stroke).Or perhaps qualifies for certain treatments (e.g. using the Centor criteria for streptococcal pharyngitis to decide whether to treat a patient with antibiotics).
Application of a simple point-of-care test to reduce UK healthcare costs and adverse events in outpatient acute respiratory infections
Published in Journal of Medical Economics, 2020
John E. Schneider, Catharina Boehme, Bettina Borisch, Sabine Dittrich
Diagnostic uncertainty coupled with the fear of missing a serious infection and patient expectations frequently drive unnecessary antibiotic prescriptions10–14. Diagnostic test offerings in the outpatient setting are limited and thus clinicians rely on history, physical exam and sometimes scoring criteria to evaluate severity of illness and need for antibiotics. Physical examination alone has a sensitivity ranging from 50 to 70% and specificity of 60–75% for diagnosing pneumonia15. The Centor criteria for identifying bacterial pharyngitis requiring antibiotics demonstrate 40–55% accuracy at identifying group A streptococcus compared to bacterial throat culture16. A FeverPAIN criteria score of 4 or 5 has a 62–65% probability of having a bacterial infection, which is slightly higher than people with a Centor score of 4 who have a 55% probability of a bacterial infection17. Further, antibiotic prescriptions are also overprescribed because they have no direct cost to the GP surgery itself and GPs often do not consider their own prescribing practices as contributing to increasing antibiotic resistance18. Of more than 1,000 UK GPs surveyed, 55% felt patient/parent pressure to prescribe antibiotics, even when unsure antibiotics were necessary, while 44% had prescribed antibiotics to get a patient to leave the clinic or surgery19. This misuse of antibiotics has been associated with antibiotic-related AEs, the emergence of resistant pathogens and rising healthcare costs.
Quality assessment in general practice: diagnosis and antibiotic treatment of acute respiratory tract infections
Published in Scandinavian Journal of Primary Health Care, 2018
Laura Trolle Saust, Lars Bjerrum, Volkert Siersma, Magnus Arpi, Malene Plejdrup Hansen
Table 1 shows the value and acceptable range for QIs focusing on the diagnostic process. Five out of the nine QIs were within the acceptable range. Nearly 90% of patients with acute pharyngotonsillitis fulfilling 2-3 modified Centor criteria (Temperature ≥38° C, tonsillar coating, tender cervical lymphadenitis, absence of cough, patient age (+ 1 point for age 3–14 years, -1 point for age less than 3 years, -1 point for age 45 years and above)) were examined with a strep A test. However, more than 70% of patients fulfilling 0-1 modified Centor criteria were also examined with a strep A test despite that Danish guidelines recommend not to test these patients. All four diagnostic QIs for patients with pneumonia fell within the acceptable range.
Throat infections and use of streptococcal antigen test and antibiotic treatment in general practice; a web-based survey
Published in Scandinavian Journal of Primary Health Care, 2022
Hanne Puntervoll, Pål Jenum, Sigurd Høye, Mette Tollånes
In Norway, approximately 84% of all antibiotics are prescribed in primary health care and approximately half are prescribed to treat respiratory tract infections [1]. Sore throat is mainly a viral infection; however, Group A Streptococcus (GAS) accounts for approximately 5–40% of the cases across populations [2]. Most cases of sore throat will resolve without treatment, but prescription of antibiotics for sore throat is frequent [3]. Inappropriate use of antibiotics may cause increase in antimicrobial resistance that has become an international public health concern. Internationally there is a lack of consensus regarding the management of sore throat. Various guidelines emphasize different approaches to diagnose and treat the condition [4]. The Norwegian guidelines recommend that clinical assessment should be performed based on the Centor criteria [5] as a tool to predict the likelihood of group A streptococcus infection and to limit unnecessary use of antibiotic therapy [6]. The Centor criteria is a four-point scoring system that helps clinicians to distinguish GAS from viral infections. Each present symptom (fever >38.5 °C, swollen and tender anterior cervical lymph nodes, tonsillar exudate and absence of cough) assigns one point which then are added to a combined score: the higher the score the higher probability of GAS infection. At Centor score 0–1, the Norwegian guidelines recommend neither rapid streptococcal antigen testing nor antibiotic therapy. At Centor score 2–3, antigen test is advised, followed by antibiotic treatment if the test is positive, and at Centor score 4, antibiotic treatment without prior antigen testing is recommended. The guidelines also give recommendations for antibiotic choice, dose, frequency, and duration of therapy [6].