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Homework answers / question archive / Title Slide: Clinical Practice Guideline: Streptococcal Pharyngitis Slide 2: Disease Background 1/2 As the name streptococcal pharyngitis suggests, this disease is characterized by inflammation of the pharynx

Title Slide: Clinical Practice Guideline: Streptococcal Pharyngitis Slide 2: Disease Background 1/2 As the name streptococcal pharyngitis suggests, this disease is characterized by inflammation of the pharynx

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Title Slide: Clinical Practice Guideline: Streptococcal Pharyngitis

Slide 2: Disease Background 1/2

As the name streptococcal pharyngitis suggests, this disease is characterized by inflammation of the pharynx. This condition is more often than not described as a sore throat by patients who have it. Moreover, many patients with this disease describe it as a “scratchy throat.” Pharyngitis cases usually spike during colder periods of the year. It is worth noting that viral pathogens like adenovirus may also cause pharyngitis. Also, other bacteria may cause pharyngitis. For instance, Bordetella pertussis is a bacteria that causes whooping cough and may cause pharyngitis. streptococcal pharyngitis is more often than not caused by group A streptococcus, a gram-positive, non-motile bacteria (Luo et al., 2019). Though pharyngitis is associated with a sore throat, it is associated with many other symptoms. In particular, chills, fatigue, coughs, runny nose and sneezing are usually associated with strep pharyngitis (Luo et al., 2019). Apart from the mentioned symptoms, strep pharyngitis might also cause pain during swallowing and unusual tastes in the mouth.

Slide 3: Disease background 2/2

Strep throat is usually caused when a person touches a surface with group A streptococcus bacteria then touching their nose, eyes or mouth. Strep throat is a bacterial infection, and so a clinician will prescribe an antibiotic and an NSAID like ibuprofen. Antibiotics that are very effective against this disease include azithromycin, cefuroxime, cefixime and amoxicillin (Luo et al., 2019). It is worth noting that frequent handwashing is the most effective method of preventing this disease. Apart from cold periods of the year, being young is also considered a risk factor for Strep pharyngitis. Strep pharyngitis can lead to various complications if it is not treated in time. Some complications associated with strep throat include the spread of infection and inflammatory reactions (Luo et al., 2019). Also, sinusitis and tonsillitis are direct results of untreated strep pharyngitis.

Slide 4: Recommendations and Applicability in Primary Practice 1/2

The 2012 clinical guideline by Shulman et al. were published on behalf of the Infectious Diseases Society of America (IDSA). This guideline was a revision to the original guideline published in 2002 by the IDSA for treatment of Group A streptococcal (GAS) pharyngitis. The authors note that the primary objective of the current guideline was to offer an update on the diagnosis and management of GAS pharyngitis, including the decisions regarding antibiotic use and dosing.

 

Slide 5: Recommendations and Applicability in Primary Practice 2/2

The guidelines are highly applicable to the primary care setting. GAS pharyngitis is a common infection associated with significant morbidity and mortality rates worldwide, especially among children. Patients typically present at the primary care setting as the first point of treatment contact. Complaints of sore throat are common among patients who visit primary care providers. The guideline support the work of primary care practitioners by offering the evidence-based support for proper diagnosis and management of the disease. The task of diagnosis and treatment are aligned with the roles of health practitioners found in the primary care setting.

Slide 6: Key Action Statements & Body of Evidence

Recommendation #1 Differential Diagnosis

The guidelines recommend that physical examinations are ineffective in differentiating between bacterial pharyngitis and viral pharyngitis and rapid antigen detection test (RADT) and/or culture should be performed (Shulman et al., 2019). This recommendation was rated as a strong recommendation based on high quality evidence. Luo et al. (2019) show that most clinicians do not follow guidelines detailing specific GAS pharyngitis diagnoses. This is dangerous as it can lead to antimicrobial resistance fueled by indiscriminate antibiotic use. It should be noted that an antigen test is rapid and effective.

Moreover, the guideline recommends anti-streptococcal antibody titers to be avoided in routine diagnosis as they are do not reflect current events. This recommendation was rated as a strong recommendation based on high quality evidence.

Recommendation #2 Treatment

The guidelines outlined by Shulman et al. (2019) recommend that penicillins be used for the treatment among patients with acute GAS pharyngitis at an appropriate dose and duration (usually 10 days). This recommendation was rated as a strong recommendation based on high quality evidence. Holm et al. (2020) agree with this recommendation as they show that Penicillin V ought to be used for long-term treatment of GAS pharyngitis though macrolides and cephalosporins can also be used. If a patient might be allergic to penicillin, they should be put on first-generation cephalosporins like Cefixime or a macrolide like clarithromycin. This sub-recommendation was rated as a strong recommendation based on moderate quality evidence.

Slide 7: Key Action Statements & Body of Evidence 2/2

Recommendation #3 Adjunct Therapy

The guideline recommends the use of NSAIDS to manage both pain and inflammation for those with moderate to severe symptoms because they are relatively safe in both children and adults. This recommendation was rated as a strong recommendation based on high quality evidence. Moreover, aspirin should be avoided among children (strong recommendation, high quality evidence) and corticosteroids should be avoided (weak recommendation, moderate quality evidence)

Recommendation #4 Chronic GAS pharyngitis Carriers

The guideline recommends the practitioner to consider those with recurrent episodes of streptococcal pharyngitis, at close intervals, and supported by laboratory evidence, to be chronic GAS pharyngeal carriers. This sub-recommendation was rated as a strong recommendation based on moderate quality evidence. However, the guidelines also insist that chronic GAS pharyngeal carriers are not likely to spread this infection. This sub-recommendation was rated as a strong recommendation based on moderate quality evidence. Finally, tonsillectomy is not recommended as a means to reducing the frequency of GAS pharyngitis among chronic sufferers. This sub-recommendation was rated as a strong recommendation based on high quality evidence.

It is worth noting that this phenomenon is more prevalent among women than men (Othman et al., 2019). Also, these people are not likely to develop complications and are usually asymptomatic and, for this reason, might need medication. However, some situations might necessitate the treatment of these patients (Shulman et al., 2012). For instance, if the patient lives with people who are concerned about GAS pharyngitis.

Slide 8: Application in Clinical Rotation

I have dealt with a case of acute GAS pharyngitis during my clinical rotation. The patient was a 18-year-old, Hispanic male. He complained of having trouble swallowing, low-grade fever and malaise, and these are some symptoms that indicated that he had a Strep throat infection. I subjected this patient to an antigen test for Strep bacteria, and it turned out positive. Since he had a history of penicillin allergies, I put him on 500mg Azithromycin OD for five days. I also put him on ibuprofen 400mg TDS for three days. Both the diagnosis and treatment of the patient’s condition was aligned with the guideline recommendations.

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