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BMC Medicine
Published in: BMC Medicine 1/2011

Open Access 01-12-2011 | Research article

Predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the Centor score

Authors: Jolien Aalbers, Kirsty K O'Brien, Wai-Sun Chan, Gavin A Falk, Conor Teljeur, Borislav D Dimitrov, Tom Fahey

Published in: BMC Medicine | Issue 1/2011

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Abstract

Background

Stratifying patients with a sore throat into the probability of having an underlying bacterial or viral cause may be helpful in targeting antibiotic treatment. We sought to assess the diagnostic accuracy of signs and symptoms and validate a clinical prediction rule (CPR), the Centor score, for predicting group A β-haemolytic streptococcal (GABHS) pharyngitis in adults (> 14 years of age) presenting with sore throat symptoms.

Methods

A systematic literature search was performed up to July 2010. Studies that assessed the diagnostic accuracy of signs and symptoms and/or validated the Centor score were included. For the analysis of the diagnostic accuracy of signs and symptoms and the Centor score, studies were combined using a bivariate random effects model, while for the calibration analysis of the Centor score, a random effects model was used.

Results

A total of 21 studies incorporating 4,839 patients were included in the meta-analysis on diagnostic accuracy of signs and symptoms. The results were heterogeneous and suggest that individual signs and symptoms generate only small shifts in post-test probability (range positive likelihood ratio (+LR) 1.45-2.33, -LR 0.54-0.72). As a decision rule for considering antibiotic prescribing (score ≥ 3), the Centor score has reasonable specificity (0.82, 95% CI 0.72 to 0.88) and a post-test probability of 12% to 40% based on a prior prevalence of 5% to 20%. Pooled calibration shows no significant difference between the numbers of patients predicted and observed to have GABHS pharyngitis across strata of Centor score (0-1 risk ratio (RR) 0.72, 95% CI 0.49 to 1.06; 2-3 RR 0.93, 95% CI 0.73 to 1.17; 4 RR 1.14, 95% CI 0.95 to 1.37).

Conclusions

Individual signs and symptoms are not powerful enough to discriminate GABHS pharyngitis from other types of sore throat. The Centor score is a well calibrated CPR for estimating the probability of GABHS pharyngitis. The Centor score can enhance appropriate prescribing of antibiotics, but should be used with caution in low prevalence settings of GABHS pharyngitis such as primary care.
Appendix
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Literature
1.
2.
Linder JA, Stafford RS: Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA. 2001, 286: 1181-1186. 10.1001/jama.286.10.1181.CrossRefPubMed
3.
Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH: Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis. 2002, 35: 113-125. 10.1086/340949.CrossRefPubMed
4.
5.
Del Mar CB, Glasziou PP, Spinks AB: Antibiotics for sore throat. Cochrane Database Syst Rev. 2006, 4: CD000023.PubMed
6.
Snellman LW, Stang HJ, Stang JM, Johnson DR, Kaplan EL: Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics. 1993, 91: 1166-1170.PubMed
7.
8.
Mirza A, Wludyka P, Chiu TT, Rathore MH: Throat culture is necessary after negative rapid antigen detection tests. Clin Pediatr (Phila). 2007, 46: 241-246. 10.1177/0009922806290219.CrossRef
9.
Anonymous: Diagnosis and treatment of streptococcal sore throat. Drug Ther Bull. 1995, 33: 9-12.CrossRef
10.
11.
Valkenburg HA, Haverkorn MJ, Goslings WR, Lorrier JC, De Moor CE, Maxted WR: Streptococcal pharyngitis in the general population. II. The attack rate of rheumatic fever and acute glomerulonephritis in patients. J Infect Dis. 1971, 124: 348-358. 10.1093/infdis/124.4.348.CrossRefPubMed
12.
Ebell MH, Smith MA, Barry HC, Ives K, Carey M: The rational clinical examination. Does this patient have strep throat?. JAMA. 2000, 284: 2912-2918. 10.1001/jama.284.22.2912.CrossRefPubMed
13.
Walsh BT, Bookheim WW, Johnson RC, Tompkins RK: Recognition of streptococcal pharyngitis in adults. Arch Intern Med. 1975, 135: 1493-1497. 10.1001/archinte.135.11.1493.CrossRefPubMed
14.
McIsaac WJ, White D, Tannenbaum D, Low DE: A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998, 158: 75-83.PubMedPubMedCentral
15.
Breese BB: A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. Am J Dis Child. 1977, 131: 514-517.PubMed
16.
Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K: The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981, 1: 239-246. 10.1177/0272989X8100100304.CrossRefPubMed
17.
Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR: Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med. 2001, 134: 506-508.CrossRefPubMed
18.
Kerdemelidis M, Lennon D, Arroll B, Peat B: Guidelines for sore throat management in New Zealand. N Z Med J. 2009, 122: 10-18.PubMed
19.
Wong SS, Wilczynski NL, Haynes RB, Ramkissoonsingh R: Developing optimal search strategies for detecting sound clinical prediction studies in MEDLINE. AMIA Annu Symp Proc. 2003, 728-732.
20.
Kastner M, Wilczynski NL, McKibbon AK, Garg AX, Haynes RB: Diagnostic test systematic reviews: bibliographic search filters ("Clinical Queries") for diagnostic accuracy studies perform well. J Clin Epidemiol. 2009, 62: 974-981. 10.1016/j.jclinepi.2008.11.006.CrossRefPubMedPubMedCentral
21.
Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J: The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol. 2003, 3: 25-10.1186/1471-2288-3-25.CrossRefPubMedPubMedCentral
22.
23.
Crawford F, Inkster M, Kleijnen J, Fahey T: Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis. Q J Med. 2007, 100: 65-86.CrossRef
24.
The Cochrane Collaboration: Review Manager (RevMan). Version 5.0. Copenhagen. 2008, Denmark: The Nordic Cochrane Centre
25.
Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH: Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol. 2005, 58: 982-990. 10.1016/j.jclinepi.2005.02.022.CrossRefPubMed
26.
Harbord R, Whiting P: metandi: Meta-analysis of diagnostic accuracy using hierarchical logistic regression. Stata J. 2009, 9: 211-229.
27.
Atlas SJ, McDermott SM, Mannone C, Barry MJ: Brief report: the role of point of care testing for patients with acute pharyngitis. J Gen Intern Med. 2005, 20: 759-761. 10.1111/j.1525-1497.2005.0143.x.CrossRefPubMedPubMedCentral
28.
Canada JM, Serna AC, Cruz NG-E, de la Iglesia JG, Ortiz LB, Fernandez MNF: Is streptococcal pharyngitis diagnosis possible?. Aten Primaria. 2007, 39: 361-365. 10.1157/13107724.CrossRef
29.
Chazan B, Shaabi M, Bishara E, Colodner R, Raz R: Clinical predictors of streptococcal pharyngitis in adults. Isr Med Assoc J. 2003, 5: 413-415.PubMed
30.
Jamiel Y: The validity of scorecard as a predictive of streptococcal pharyngitis by throat swab. Dissertation: MMSc. University of Auckland. 2005, New Zealand, Department of General Practice and Primary Health Care
31.
Johansson L, Månsson NO: Rapid test, throat culture and clinical assessment in the diagnosis of tonsillitis. Fam Pract. 2003, 20: 108-111. 10.1093/fampra/20.2.108.CrossRefPubMed
32.
Kljakovic M: Sore throat presentation and management in general practice. N Z Med J. 1993, 106: 381-383.PubMed
33.
Lindbaek M, Høiby EA, Lermark G, Steinsholt IM, Hjortdahl P: Clinical symptoms and signs in sore throat patients with large colony variant B-haemolytic streptococci groups C or G versus group A. Br J Gen Pract. 2005, 55: 615-619.PubMedPubMedCentral
34.
35.
Meland E, Digranes A, Skjaerven R: Assessment of clinical features predicting streptococcal pharyngitis. Scand J Infect Dis. 1993, 25: 177-183. 10.3109/00365549309008482.CrossRefPubMed
36.
Rosenberg P, McIsaac W, MacIntosh D, Kroll M: Diagnosing streptococcal pharyngitis in the emergency department: is a sore throat score approach better than rapid streptococcal antigen testing?. CJEM. 2002, 4: 178-184.CrossRefPubMed
37.
Treebupachatsakul P, Tiengrim S, Thamlikitkul V: Upper respiratory tract infection in Thai adults: prevalence and prediction of bacterial causes, and effectiveness of using clinical practice guidelines. J Med Assoc Thai. 2006, 89: 1178-1186.PubMed
38.
Humair JP, Revaz SA, Bovier P, Stalder H: Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings. Arch Intern Med. 2006, 166: 640-644. 10.1001/archinte.166.6.640.CrossRefPubMed
39.
Llor C, Hernandez Anadon S, Gomez Bertomeu FF, Santamaria Puig JM, Calvino Dominguez O, Fernandez Pages Y: Validation of a rapid antigenic test in the diagnosis of pharyngitis caused by group a beta-haemolytic Streptococcus. Aten Primaria. 2008, 40: 489-494. 10.1157/13127228.CrossRefPubMed
40.
Seppala H, Lahtonen R, Ziegler T, Meurman O, Hakkarainen K, Miettinen A, Arstila P, Eskola J, Saikku P, Huovinen P: Clinical scoring system in the evaluation of adult pharyngitis. Arch Otolaryngol Head Neck Surg. 1993, 119: 288-291.CrossRefPubMed
41.
Vergouwe Y, Steyerberg EW, Eijkemans MJ, Habbema JD: Validity of prognostic models: when is a model clinically useful?. Semin Urol Oncol. 2002, 20: 96-107. 10.1053/suro.2002.32521.CrossRefPubMed
42.
Poses RM, Cebul RD, Collins M, Fager SS: The importance of disease prevalence in transporting clinical prediction rules. The case of streptococcal pharyngitis. Ann Intern Med. 1986, 105: 586-591.CrossRefPubMed
43.
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009, 6: e1000097-10.1371/journal.pmed.1000097.CrossRefPubMedPubMedCentral
44.
Heckerling PS, Harris AA: Streptococcal pharyngitis in an adult emergency room population. J Fam Pract. 1985, 21: 302-307.PubMed
45.
Gulich M, Triebel T, Zeitler H: Development and validation of a simple, two step algorithm to identify streptococcal infection in adults with sore throat. Eur J Gen Pract. 2002, 8: 57-61. 10.3109/13814780209160834.CrossRef
46.
Komaroff AL, Pass TM, Aronson MD, Ervin CT, Cretin S, Winickoff RN, Branch WT: The prediction of streptococcal pharyngitis in adults. J Gen Intern Med. 1986, 1: 1-7. 10.1007/BF02596317.CrossRefPubMed
47.
Solak S, Ergonul O: Short communication: clinical predictors of group A beta hemolytic streptococci isolation in upper respiratory tract infections. Mikrobiyol Bul. 2005, 39: 333-337.PubMed
48.
Grimes DA, Schulz KF: Refining clinical diagnosis with likelihood ratios. Lancet. 2005, 365: 1500-1505. 10.1016/S0140-6736(05)66422-7.CrossRefPubMed
49.
Wigton RS, Connor JL, Centor RM: Transportability of a decision rule for the diagnosis of streptococcal pharyngitis. Arch Intern Med. 1986, 146: 81-83. 10.1001/archinte.146.1.81.CrossRefPubMed
50.
Leeflang MM, Scholten RJ, Rutjes AW, Reitsma JB, Bossuyt PM: Use of methodological search filters to identify diagnostic accuracy studies can lead to the omission of relevant studies. J Clin Epidemiol. 2006, 59: 234-240. 10.1016/j.jclinepi.2005.07.014.CrossRefPubMed
51.
Centor RM, Dalton HP, Campbell MS, Lynch MR, Watlington AT, Garner BK: Rapid diagnosis of streptococcal pharyngitis in adult emergency room patients. J Gen Intern Med. 1986, 1: 248-251. 10.1007/BF02596194.CrossRefPubMed
52.
Gerber MA, Shulman ST: Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev. 2004, 17: 571-580. 10.1128/CMR.17.3.571-580.2004.CrossRefPubMedPubMedCentral
53.
Choby BA: Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009, 79: 383-390.PubMed
54.
Neuner JM, Hamel MB, Phillips RS, Bona K, Aronson MD: Diagnosis and management of adults with pharyngitis. A cost-effectiveness analysis. Ann Intern Med. 2003, 139: 113-122.CrossRefPubMed
55.
McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE: Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA. 2004, 291: 1587-1595. 10.1001/jama.291.13.1587.CrossRefPubMed
56.
Bont J, Hak E, Hoes AW, Macfarlane JT, Verheij TJ: Predicting death in elderly patients with community-acquired pneumonia: a prospective validation study reevaluating the CRB-65 severity assessment tool. Arch Intern Med. 2008, 168: 1465-1468. 10.1001/archinte.168.13.1465.CrossRefPubMed
57.
Brindle P, Beswick A, Fahey T, Ebrahim S: Accuracy and impact of risk assessment in the primary prevention of cardiovascular disease: a systematic review. Heart. 2006, 92: 1752-1759. 10.1136/hrt.2006.087932.CrossRefPubMedPubMedCentral
58.
Worrall G, Hutchinson J, Sherman G, Griffiths J: Diagnosing streptococcal sore throat in adults: randomized controlled trial of in-office aids. Can Fam Physician. 2007, 53: 667-671,666.
59.
Linder JA, Chan JC, Bates DW: Evaluation and treatment of pharyngitis in primary care practice. The difference between guidelines is largely academic. Arch Intern Med. 2006, 166: 1374-1379. 10.1001/archinte.166.13.1374.CrossRefPubMed
60.
McIsaac WJ, Goel V, To T, Permaul JA, Low DE: Effect on antibiotic prescribing of repeated clinical prompts to use a sore throat score: lessons from a failed community intervention study. J Fam Pract. 2002, 51: 339-344.PubMed
61.
Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, Sam J, Haynes RB: Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005, 293: 1223-1238. 10.1001/jama.293.10.1223.CrossRefPubMed
62.
Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J: Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ. 2009, 339: b2885-10.1136/bmj.b2885.CrossRefPubMedPubMedCentral
Metadata
Title
Predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the Centor score
Authors
Jolien Aalbers
Kirsty K O'Brien
Wai-Sun Chan
Gavin A Falk
Conor Teljeur
Borislav D Dimitrov
Tom Fahey
Publication date
01-12-2011
Publisher
BioMed Central
Published in
BMC Medicine / Issue 1/2011
Electronic ISSN: 1741-7015
DOI
https://doi.org/10.1186/1741-7015-9-67

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