Niger J Paed 2013; 40 (1): 1 –5  
Sadoh WE  
Sadoh AE  
Need for a clinical decision rule for  
the management of pharyngitis in  
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.  
Tel: +2348028809710  
Sadoh AE  
Institute of Child Health,  
University of Benin,  
Benin City,  
Keywords: Clinical decision rule,  
pharyngitis, antibiotic resistance,  
group A Streptococcus.  
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 is a common cause of ou,2t-patient presenta-  
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  
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-  
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  
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-  
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  
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  
than one third of under-fives’ deaths from pneumonia.  
Acute respiratory infections in turn0 contributes 15% to  
under fives mortality in Nigeria. The impact of un-  
checked antibiotic resistance to Streptococcal pneumo-  
nia would be enormous on childhood mortality.  
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.  
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-  
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  
derived by Centor et al in 1980. It comprised the use of  
four criteria; tender cervical adenopathy, fever, absence  
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  
The modified Centor score by McIsaac et  
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  
. 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  
pharyngitis as has been shown in other studies.  
will go a long way in reducing antibiotic resistance in  
the country.  
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-  
Table 1: Modified Centor score  
Absence of cough  
Tender and swollen cervical glands  
Temperature >380C  
Tonsillar swelling or exudates  
stead. This means that not only penicillin is exposed to  
resistance but other medicines and thus increasing the  
antibiotic resistance problem.  
– 14 year  
5 – 44 year  
45 years  
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 GAS 3p1,3h2aryngitis 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  
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,3f2 pharyngitis 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-  
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-  
duced a scoring system which resulted in a 35% to 55%  
reduction in unnecessary 28antibiotic 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.  
prevalence are different, they don’t not work well. It is  
thus important to develop a National CDR for Nigeria.  
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.  
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  
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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