REVIEW

Niger J Paed 2013; 40 (1): 1 –5

Sadoh WE

Sadoh AE

Need for a clinical decision rule for

the management of pharyngitis in

Nigeria.

DOI:http://dx.doi.org/10.4314/njp.v40i1.1

Accepted: 26th May 2012

Abstract Pharyngitis is a common

reason for presentation in the hospi-

tal by children. Although viral aeti-

ology is the commonest, Group A

Streptococcus is the most important

cause of and reason for antibiotic

treatment of pharyngitis. The fact

that GAS causes the non suppura-

tive sequalae of rheumatic fever and

acute glomerulonephritis perhaps

drives the empirical antibiotic treat-

ment of most cases of pharyngitis.

The unnecessary antibiotic treat-

ment contributes to antibiotic resis-

tance, a major public health prob-

lem. While it is desirable to do

throat culture to guide the physi-

cian’s management of each case,

the required laboratory skill is un-

available in most clinical settings in

Nigeria. A clinical decision rule

(CDR) which is a clinical tool that

helps guide physicians in the man-

agement of conditions such as

pharyngitis, have been shown to be

helpful in managing pharyngitis in

other countries. It reduces the num-

ber of unnecessary antibiotic pre-

scriptions and has a high sensitivity

and specificity in distinguishing

GAS from non GAS pharyngitis.

Currently there are no guidelines or

CDR for the management of

pharyngitis in Nigeria, there is an

urgent need to derive, validate and

implement a CDR to guide the

treatment of pharyngits.

(

)

Sadoh WE

Department of Child Health

University of Benin/University of

Benin Teaching Hospital,

Benin City, Nigeria.

E-mail: sadohehi@yahoo.com

Tel: +2348028809710

Sadoh AE

Institute of Child Health,

University of Benin,

Benin City,

Nigeria.

Keywords: Clinical decision rule,

pharyngitis, antibiotic resistance,

group A Streptococcus.

Introduction

treatment with appropriate antibiotic prevents RF and

thus RHD, encourages the prescription of antibiotic for

the treatment of most cases of pharyngitis in the absence

of laboratory confirmation of the causative agent. These

unnecessary antibiotic prescriptions portend grave con-

sequences for the nation as they cause antibiotic resis-

tance. Laboratory services are lacking in most clinical

settings in Nigeria. Alternatives to laboratory services

are clearly needed to facilitate the discrimination be-

tween GAS and non GAS cases of pharyngitis to guide

antibiotic prescription. The clinical decision rule (CDR)

is a cheap and efficient alternative where laboratory ser-

vices may be lacking. A CDR is a clinical tool often

consisting of weighted clinical features, it assist clini-

cians with the diagnosis, prognosis and treatment of a

given condition. The CDR is used in many clinical

conditions one of which is in the management of

pharyngitis.

Pharyngitis is a common cause of ou_,₂t-patient presenta-

1

tion amongst children and adults. The commonest

cause of pharyngitis is viral. Bacterial causes are impor-

tant causes of pharyngitis as they may require treatment

with antibiotic. Three of the bacterial causes, group A β

haemolytic Streptococcus (GAS) is the most common

and most pathogenic bacterial aetiology because i₄t

causes both suppurative and non suppurative sequalae.

GAS contributes 15 – 30 % of cases of pharyngitis in

5

children and 5 – 20% in adults. GAS pharyngitis is

transmitted by respiratory droplets and the incubation

period is 24 to 72 hours.5 Children in crowded situations

such as schools, and hostels are thus particularly vulner-

able.

The non suppurative sequalae of rheumatic fever (RF)

and rheumatic heart disease (RHD) are of major public

health concern in developing countries where they are

still prevalent and contribute the majority of the 16 mil-

lion cases of RHD globally and the greater proportion of

the over 200,000 death attributable to RHD globally.6

The prevalence of RHD in Nigeria is 0.07/1000 among

primary school children aged six to twelve years. 7RHD

is r₈e_,s₉ponsible for 7 – 68% of all heart diseases in Nige-

ria. The age group 5 to 15 years is commonly affected.

The fact that GAS pharyngitis results in RF and that its

Clinical diagnosis of pharyngitis

Clinical evaluation of cases of pharyngitis provides an

opportunity to distinguish between viral and bacterial

aetiology. In viral cases, the children may present insidi-

ously and often₁₀with coryza, conjunctivitis, cough, fever

and diarrhoea. Bacterial pharyngitis on the other hand

presents with sudden onset, fever, tender cervical ade-

nopathy, presence of pharyngeal exudates, sorethroat

2

1

and absence of cough. In clinical practice the ability to

visit medicine stores where antibiotics maybe procured

based on the purchasing power of the patients.This

suboptimal treatment may contrib₁u₇te to resistance which

is a major public health problem. Also, the inadequate

treatment of pharyngitis may not prevent RF since the

immunologic damage may still occur despite the relief

the patient may have from the symptoms. The initiation

and sustenance of a programme using RADT will be

difficult in resource limited setting such as ours except it

is heavily subsidized.

discriminate GAS from non GAS using the aforemen-

tioned clin₁₁ical signs and symptoms is possible in half of

the cases. There may be overlap between features mak-

ing discrimination difficult, besides no one feature has

proven to have that discriminating ability between viral

and bacteria pharyngitis. However when the presence of

multiple signs and symptoms are used as in CDR, the

diagnostic accuracy of making this clinical decision im-

proves.

Primary prevention of RF/RHD

Antibiotic resistance

The importance of promptly and adequately treating

GAS pharyngitis is the basis of primary prevention of

RF. Primary prevention is being advocated as the way

forward in reducing the burden of RHD in Africa. Sec-

ondary prevention strategy only, which involves the

placement of the affected individual on penicillin pro-

phylaxis may not be enough to combat this scourge.

A major consequence of indiscriminate antibiotic pre-

scription for viral pharyngitis, is antibiotic resistance.

Other major contributors are incomplete or inadeq₁u₇ate

dosing and antibiotic use among livestock globally. In

1

2

1

8

a study in Jos, Nigeria, the prevalence of penicillin

resistant Streptococcus pneumoniae was found to be

29.72%. The organisms were resistant to commonly

used antimicrobials which included penicillin, ampicilin,

genticin, chloramphenicol erythromycin and ciproflox-

acin. Streptococcus pneumoniae is responsible for more

Since primary prevention involves the identification of

the child with GAS pharyngitis for antibiotic treatment.

Laboratory backup will be needed to culture the throat

swabs from affected children. The determination of the

Lancefield group of the β haemolytic streptococcus to

ascertain if it is group A will also be required. This level

of laboratory skills is absent in most health facilities in

Nigeria. Thus attending physicians may have difficulty

in making a decision on whether to prescribe antibiotic

for pharyngitis or not in the absence of laboratory ser-

vices. The option of commencing the most children with

pharyngitis on antibiotic while awaiting laboratory result

exposes them to inadequate antibiotic doses since the

medication will be stopped following a negative culture.

The patient may all together not revisit the health facility

as would be requested by the physician especially when

the child is getting better, compliance to medication may

then become questionable. The physician in an attempt

to err on the side of caution often resort to prescri₃bing

1

9

than one third of under-fives’ deaths from pneumonia.

Acute respiratory infections in turn₀ contributes 15% to

2

under fives mortality in Nigeria. The impact of un-

checked antibiotic resistance to Streptococcal pneumo-

nia would be enormous on childhood mortality.

2

1

In another study in Ibadan. high rates of antimicrobial

resistance was noted in pathogens ranging from Staphy-

lococcus aureus to gram negative bacilli such as kleb-

siella spp. They were again mostly resistant to common

medicines such as amoxicillin/clavulanate, cefuroxine,

genticin, penicillin and chloramphenicol. Physicians are

known to prescrib₁₃e a variety of medicines for children

with pharyngitis. When the common antibiotics fail,

prescribers will resort to the more expensive and newer

antibiotics. The cost of treatment becomes quite high

resulting from cost of medicines and longer hospital

stay. Antibiotic resistance becomes a major contributor

to childhood morbidity and mortality. This doubtless

will place a huge financial and social burden on the af-

fected families and the Nation. Reducing the indiscrimi-

nate antibiotic prescription for pharyngitis will thus

ameliorate the pressure on antibiotic and reduce the

chances of antibiotic resistance.

1

antibiotic for all cases of pharyngitis. Sadoh et al re-

ported that 56.4 % of physicians surveyed in the mid

Western part of Nigeria would prescribe antibiotic em-

pirically for all patients with pharyngitis. Perhaps simi-

lar antibiotic prescription pattern obtains in other parts

of the country.

In developed countries, rapid antigen detection test

(

RADT) for GAS₄ is used in the place of full microbi-

1

The use of clinical decision rule

ological culture. This has the advantage of providing

rapid results and requires less expertise to perform. The

use of RADT is however limited because the sensitivity

may not be as good as microbiological cultures. Thus

patients who are RADT negative maybe required to do

culture.15 The newer ELISA, optical immunoassays and

assay employing the chemiluminiscent DNA probes

have sensitivities upto 90 – 99 % compared with micro-

biological culture and thus the requir₁e₆ment for microbi-

ological culture may not be needed. These newer test

kits are quite expensive and mark up the cost of treating

pharyngitis. This extra cost may prevent patients from

presenting in the health facilities preferring instead to

To prevent the indiscriminate prescription of antibiotics

for non GAS pharyngitis, the physician must be able to

distinguish bacterial from viral and non infective causes

of pharyngitis. In the absence of laboratory services, the

doctors may have to use a set of clinical signs and symp-

toms as the basis for deciding whether to prescribe or

not to prescribe antibiotic for a given case of pharyngi-

tis, the so CDR.

The most popular and₂ perhaps the earliest CDR was

2

derived by Centor et al in 1980. It comprised the use of

four criteria; tender cervical adenopathy, fever, absence

3

7

,30

of cough and pharyngeal exudates. The presence of all

four was said to give a high probability of the GAS

pharyngitis while the presence of two or three features

will necessitate the culturing of the throat swab or use of

rapid antigen detection test. The Centor criteria was es-

tablished for patients 15 years and above. It is good in

identifying individuals with low risk for GAS pharyngi-

tis and reduces the proportion of unnecessary antibiotic

prescription, having been validated by a number of stud-

ies where₂₃_,h₂₄igh sensitivity and specificity results were

haemolytic Streptococcus were obtained respectively.

The difference in prevalence suggests the need to de-

velop and validate different CDRs in different parts of

the country to crystallise a CDR that best capture the

entire country for implementation.

The importance of clinical decision rule

Once a CDR is established for the country, attending

physicians will be guided by it. This will enhance the

primary prevention strategy of RF/RHD in the country

as likely GAS pharyngitis will be adequately treated.

This together with effective implementation of the sec-

ondary prevention strategy and health educating the both

the prescribers and the populace, will lead to reduction

in the burden of RF and RHD. There will be a reduction

in the prescription of unnecessary antibiotics for

obtained.

The modified Centor score by McIsaac et

26

2

5

al was validated in over 600 children and adults. In

addition to the four Centor criteria, age was included as

a criterion. The criteria are scored as shown in the table

1

. Patients <15 years were given an extra score of one

while in those between 15 and 44 years were scored

zero. A score of one was subtracted from those 45 years

and above. Decisions were taken based on the score ob-

tained from evaluating the patients as shown in Table 1.

The sensitivity and specificity of the modified Centor

clinical scoring system in identifying GAS was 85% and

26,28

pharyngitis as has been shown in other studies.

This

will go a long way in reducing antibiotic resistance in

the country.

9

6

2.1% respectively. Using the scoring tool resulted in

3.7% reduction in antibiotic prescription compared to

Antibiotic treatment of pharyngitis

the usual physician practice.

It is also important that a clear first line medicine for the

treatment of pharyngitis is established nationally. Tradi-

tionally penicillin V is the drug of choice, however in a

study on physicians’ management of sore throat in Be-

nin City; most doctors did not comply with the use of

penicillin as first line medicine. A variety of medicines

were b₃eing prescribed for pharyngitis in children in-

2

5

Table 1: Modified Centor score

Criteria

Points

Absence of cough

Tender and swollen cervical glands

Temperature >380C

Tonsillar swelling or exudates

Age

1

stead. This means that not only penicillin is exposed to

resistance but other medicines and thus increasing the

antibiotic resistance problem.

3

1

>

– 14 year

5 – 44 year

45 years

1

0

-1

Because of the difficulty with compliance with a ten day

course of penicillin, the effectiveness of other alternative

medicines such as amoxylcillin and cefuroxine in ade-

quately treating GAS₃p₁_,₃h₂aryngitis have been demon-

Cumulative score

strated in other studies.

The issue of poor compliance

Score 0 or 1 (low risk) no testing and no antibiotic

Score of 2 and 3 (medium risk) perform testing and give antibiotic if

positive

with medication also contributes to antibiotic resistance,

there are studies that have evaluated the efficacy of

shorter duration and dosing of medicines used in the

treatment₃₁o_,₃f₂pharyngitis compared to standard treatment

Score 4, (high risk), consider giving antibiotic empirically

Since the Centor criteria, a number of CDRs have been

derived by o₂t₇h_,₂e₈r workers in bo₂t₇h developing and devel-

regimen.

Single Benzathin penicillin injection has

also been shown to be effective and is being used in

Brazil to enhance treatment compliance in cases of

oped world.

Joachim et al working in Brazil pro-

3

duced a scoring system which resulted in a 35% to 55%

reduction in unnecessary₂₈antibiotic prescription while

the one by Smeester et al had a sensitivity of 92% and

resulted in a 31% to 38% reduction in antibiotic pre-

scription for culture negative pharyngitis. CDRs work

best in the populations in which they are derived and in

populations with similar GAS prevalence. Where the

pharyngitis. Single injection of penicillin maybe quite

useful to ensure compliance to therapy in our setting for

the children without penicillin allergy. Benzathin peni-

cillin has continued to be efficacious in clinical settings.

2

9

prevalence are different, they don’t not work well. It is

thus important to develop a National CDR for Nigeria.

Conclusion

There is a paucity of studies on agents causing pharyngi-

tis in patients in Nigeria and no CDR has yet been de-

rived for facilitating the management of pharyngitis in

Nigeria. The prevalence of GAS is different from locale

to locale as shown in two studies from Benin City and

Lagos where values of 0 % and 22.8% of the cases of β

Managing pharyngitis in children without laboratory

backup is a common problem physicians are faced with

in most clinical settings across the nation. In order to

prevent the occurrence of RF, alot of unnecessary antibi-

otics are prescribed. This leads to antibiotic resistance

which is a growing global concern.

4

A wide variety of common medicines are involved.

Periodic evaluation of the efficacy of current medicine

of choice is important in the face of antibiotic resistance

and so guides prescribers as to the optimal medicine for

the treatment of pharyngitis. The current situation in the

country is that antibiotics are prescribed indiscriminately

in the absence of guideline and the choices of antibiotics

are left to the prescribers’ whim. This situation can only

be arrested if concerted efforts are made by the Ministry

of Health through research to establish not only a CDR

in the management of pharyngitis but also the choice of

medicine to prescribe when the need arises.

It is imperative to guide all prescribers in the absence of

a national CDR. Perhaps the modified Centor criteria be

recommended as guideline pending when a national

CDR is established. The Integrated Management of

Childhood Illnesses (IMCI) programme is a veritable

tool for cascading the process down to community ex-

tension workers and allied health workers by incorporat-

ing a guideline on treatment of pharyngitis in the IMCI

3

4

as has been done with the IMCI programme in Turkey.

It is also important to educate the health community on

appropriate antibiotic prescription and the dangers posed

by indiscriminate antibiotic use.

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