Volume 210 - Issue 10
Call for a national sore throat guideline
Authors: Adrian J Tarca, Robert M Hand and Rosemary Wyber
Med J Aust 2019; 210 (10): 477-477.e1. || doi: 10.5694/mja2.50166
Published online: 3 June 2019
Published online: 3 June 2019
To the Editor: Pharyngitis, a common childhood illness, accounts for around 3% of presentations to general practice in Australia.1 Although usually benign and self‐limiting, group A streptococcus (GAS) pharyngitis, isolated in up to 20% of symptomatic children,2 can lead to infectious and autoimmune sequelae. Despite Australia being a high income country, acute rheumatic fever (ARF) and rheumatic heart disease (RHD) still cause significant morbidity and mortality in Aboriginal and Torres Strait Islander people.3
Prompt treatment of GAS pharyngitis has been shown to reduce the incidence of ARF by two‐thirds in high risk individuals.4 Low risk individuals require supportive management only.5 Clinical diagnosis of GAS pharyngitis is unreliable4 and culture results take time. As such, clinicians must balance the competing priorities of appropriate treatment of patients at high risk of ARF or RHD with prudent antimicrobial stewardship. Clinical practice guidelines play an important role in decision making at both a population and individual level.
We undertook a search to identify Australian and New Zealand pharyngitis guidelines and compared these with previously published criteria.6 Nine guidelines were identified. Inconsistences in diagnosis, definition of high risk groups, analgesia, antibiotic rationale, agent, therapy duration, and tonsillectomy indications were observed (Box).
Australia's multitude of heterogenic guidelines coupled with the transient workforce in remote Australia, where ARF burden is the highest,7 predispose to management confusion and potential poor patient outcomes, including higher rates of ARF and RHD, and also fail to address the growing worldwide problem of antimicrobial resistance.
Australia needs a single national pharyngitis guideline to assist in providing rational, consistent and timely antibiotic treatment to patients at high risk of ARF, while minimising inappropriate antibiotic usage and resistance in individuals at low risk of sequelae. We call for an evidence‐based guideline that includes the following:
- a clear, succinct approach to diagnosis and management;
- a definition of individuals at high risk of ARF, and rationale for antibiotic treatment;
- clear guidance regarding throat culture and point‐of‐care testing for GAS;
- rationale for first‐ and second‐line empirical antibiotics, with alternatives for penicillin allergy;
- capacity to adapt management in different clinical settings; and
- supportive care recommendation including analgesia, tonsillectomy and school exclusion.
Box – Summary of selected criteria:6 are criteria addressed by each sore throat guideline?
Guidelines |
NZ HF |
BPAC NZ |
CH QLD |
NSW ICCPG |
CARPA |
RHD Aust |
PCH |
RCH |
eTG | ||||||
Number of criteria addressed |
6/12 |
7/12 |
2/12 |
10/12 |
7/12 |
6/12 |
10/12 |
9/12 |
10/12 |
||||||
Diagnostic criteria |
× |
× |
× |
✓ |
✓ |
× |
✓ |
× |
✓ |
||||||
Routine throat culture/rapid antigen detection testing |
✓ |
✓ |
× |
✓ |
× |
✓ |
✓ |
✓ |
× |
||||||
Antibiotics to reduce symptoms |
× |
✓ |
× |
✓ |
× |
× |
✓ |
× |
✓ |
||||||
Antibiotics to prevent complications |
✓ |
✓ |
× |
✓ |
✓ |
✓ |
✓ |
✓ |
✓ |
||||||
NZHF = New Zealand Heart Foundation (http://www.heartfoundation.org.nz/shop/heart-healthcare/non-stock-resources/sore-throat-algorithm.pdf); BPAC = Best Practice Advocacy Centre (https://bpac.org.nz/antibiotics/guide.aspx#sore-throat); CH QLD = Children's Health Queensland Hospital and Health Service guidelines (http://www.childrens.health.qld.gov.au/chq/health-professionals/antimicrobial-stewardship/guidelines/ent-infections); NSW ICCPG = New South Wales infants and children clinical practice guidelines (http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_021.pdf); CARPA = Central Australian Rural Practitioners Association's standard treatment manual (https://docs.remotephcmanuals.com.au/review/g/manuals2017-manuals/d/20321.html?page=115); RHD Aust = rheumatic heart disease Australian guidelines (https://www.rhdaustralia.org.au/arf-rhd-guideline); PCH = Perth Children's Hospital emergency department guidelines (https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Tonsillitis); RCH = Royal Children's Hospital Melbourne guidelines (with support of the Victorian Paediatric Clinical Network) (www.rch.org.au/clinicalguide/guideline_index/Sore_throat); eTG = electronic therapeutic guidelines (https://tgldcdp.tg.org.au/searchAction?appendedInputButtons=sore%20throat). ◆ | |||||||||||||||
Competing interests
No relevant disclosures.
Acknowledgements
We acknowledge the contribution of Asha Bowen to this review and analysis. Rosemary Wyber is supported by a National Health and Medical Research Council Postgraduate Scholarship (1151165).
References
- Dallas A, van Driel M, Morgan S, et al. Antibiotic prescribing for sore throat: a cross‐sectional analysis of the ReCEnT study exploring the habits of early‐career doctors in family practice. Fam Pract 2016; 33: 302–308.
- Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55: 1279–1282.
- Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2017: acute rheumatic fever and rheumatic heart disease. Supplementary online tables [Cat. No. WEB 194]. Canberra: AIHW, 2017. https://www.aihw.gov.au/reports/indigenous-health-welfare/health-performance-framework/contents/tier-1-health-status-and-outcomes/1-06-acute-rheumatic-fever-rheumatic-heart-disease (viewed May 2018).
- Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev 2013; (11): CD000023.
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- Noonan BN, Zurynski YA, Currie BJ, et al. A national prospective surveillance study of acute rheumatic fever in Australian children. Pediatr Infect Dis J 2013; 32: e26–e32.