3. “We need ways to target all
behaviours that contribute to the
misuse of these fragile medicines.”
Dr. Margaret Chan
New York, USA
April 18, 2016
2
4. Core competencies for
antimicrobial prescribing
C1: Understands the patient and the patient’s clinical needs
C2: Understands treatment options and how they support the
patient’s clinical needs
C3: Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
C4: Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
C5: Monitors and reviews the patient’s response to treatment
3
Core Competencies
5. Objectives
• Understand the epidemiology of infectious etiologies of acute
pharyngitis
• Use clinical prediction scores and microbiologic tests to
identify those that may benefit from antimicrobial therapy.
• Recognize communication tools that can be used to educate
patients about their diagnoses and the appropriate use of
antimicrobials
4
6. Acute pharyngitis
5
• Common target for
antimicrobial stewardship
– Majority due viral
infections
– Broad-spectrum
antimicrobials used
inappropriately
Lord Akryl (http://cancer.gov) [Public domain], via Wikimedia Commons
7. Harm associated with antimicrobials
• Adverse events
• Clostridium difficile
colitis
• Cost
• Emergence of
antimicrobial resistance
6
10. 14 year-old male with:
2 day history of sore throat & fever
no rhinorrhea or cough
temperature 38.5o C
no acute distress
erythematous posterior pharynx with
exudate
9
11. Streptococcus pyogenes
10
• Group A Streptococcus
• Most common bacterial
etiology of pharyngitis
• More common in children
• Estimated to cause
5-15% of cases of sore
throat in adults
U.S. Centers for Disease Control and Prevention –
Medical Illustrator
14. Modified Centor Score
13
Criteria Point
Temperature >38C 1
No cough 1
Tender anterior cervical
adenopathy
1
Tonsillar swelling or exudate 1
Age 3 -14 years 1
Age 15 – 44 years 0
Age > 44 years -1
Total
Score
Risk of group A
streptococcal
pharyngitis
≥ 4 38 – 63%
3 27 – 28%
2 10 – 12%
1 4 – 6%
0 2 – 3%
15. Diagnostic challenges
• Validated prediction
scores have limitations.
• May help determine who
does not need testing
• A positive microbiologic
test may represent
carriage
14
WHO/A. Kristensen
17. Rapid antigen testing
16
A rapid antigen diagnostic
tests that is negative for
Group A Streptococcal
pharyngitis provides
reassurance that a
antibiotics are unlikely to be
needed.
WHO/A. Kristensen
19. 14 year-old male with:
2 day history of sore throat & fever
no rhinorrhea or cough
temperature 38o C
no acute distress
erythematous posterior pharynx with
exudate
18
20. An informed choice
Severity Source
Drug
resistance
Patient
factors
Cultures
Core Competencies 1 & 2
Optimal antibiotics
19
22. What is the likely source & pathogens?
Severity Source
Drug
resistance
Patient
factors
Cultures
• Group A Streptococcus pharyngitis?
• No signs of viral URI
21
23. What is the likely source & pathogens?
Severity Source
Drug
resistance
Patient
factors
Cultures
22
Criteria Point
Temperature >38C 1
No cough 1
Tender anterior cervical
adenopathy
-
Tonsillar swelling or exudate 1
Age 3 -14 years 1
Age 15 – 44 years -
Age > 44 years -
TOTAL 4
Total
Score
Risk of group A
streptococcal
pharyngitis
≥ 4 38 – 63%
3 27 – 28%
2 10 – 12%
1 4 – 6%
0 2 – 3%
29. 55 year-old male with:
2 day history of sore throat & fever
+ rhinorrhea and mild cough
temperature 38.2o C
no acute distress
erythematous posterior pharynx with
exudate
28
31. What is the likely source & pathogens?
Severity Source
Drug
resistance
Patient
factors
Cultures
Viral upper respiratory tract
infection most likely
30
32. What is the likely source & pathogens?
Severity Source
Drug
resistance
Patient
factors
Cultures
31
Criteria Point
Temperature >38C 1
No cough -
Tender anterior cervical
adenopathy
-
Tonsillar swelling or exudate 1
Age 3 -14 years -
Age 15 – 44 years -
Age > 44 years -1
TOTAL 1
Total
Score
Risk of group A
streptococcal
pharyngitis
≥ 4 38 – 63%
3 27 – 28%
2 10 – 12%
1 4 – 6%
0 2 – 3%
37. 36
Group A streptococcal causes:
– 20 – 30% pharyngitis in
children
– 5 – 15 % of pharyngitis in
adults
Pharyngitis in adults
By Lord Akryl (http://cancer.gov) [Public domain], via Wikimedia Commons
38. 37
Important to educate
patients that the majority
of patients with sore
throat do well without
antibiotics.
Patient expectations may drive
inappropriate antibiotic use
39. 38
Consider asking patients
directly if they expect to
receive antibiotics during
this encounter and why
to facilitate
communication.
Clinicians may overestimate their
patients desire for antibiotics
40. Review: Pharyngitis in Adults & Adolescents
Drug
Dose
Duration
Route
prescription
.............
.............
.............
39
41. Review: Pharyngitis in Adults & Adolescents
Drug
Dose
Duration
Route
prescription
.............
.............
.............
Acute pharyngitis in adults is
most commonly caused by a
viral infection.
42. Review: Pharyngitis in Adults & Adolescents
Clinical prediction scores can be
used to determine which patients
should undergo microbiologic
testing for Group A
Streptococcal pharyngitis.
Drug
Dose
Duration
Route
prescription
.............
.............
.............
43. Review: Pharyngitis in Adults & Adolescents
Drug
Dose
Duration
Route
prescription
.............
.............
.............
Penicillin is first-line therapy in
non-allergic patients diagnosed
with streptococcal pharyngitis.
44. Review: Pharyngitis in Adults & Adolescents
Drug
Dose
Duration
Route
prescription
.............
.............
.............
Directly ask regarding your
patient’s expectations for
antibiotics to facilitate
communication.
