Strategies for managing group A streptococcal pharyngitis. A survey of board-certified pediatricians
C. Hofer, H. J. Binns and R. R. Tanz
Department of Pediatrics, Children's Memorial Hospital, Northwestern University Medical School, Chicago, Ill., USA.
OBJECTIVE: To assess the management strategies and knowledge of
board-certified pediatricians regarding group A beta-hemolytic
streptococcal (GABHS) pharyngitis. DESIGN: Survey of 1000 US pediatricians
in 1991, chosen randomly from the membership of the American Academy of
Pediatrics. The survey included questions related to 2 clinical scenarios,
respondent demographics, and knowledge of streptococcal pharyngitis.
SUBJECTS: Pediatricians who treated patients with pharyngitis. Of the 690
surveys that were returned, 510 pediatricians treated patients with
pharyngitis and were included in the data analysis. DATA ANALYSIS: Data
were analyzed using Chi 2 statistics for categorical data and the Student t
test for continuous variables. RESULTS: Antigen detection tests (ADTs) were
used by 64% of the pediatricians; 85% used throat cultures. Strategies for
diagnosing streptococcal pharyngitis were throat culture alone (38%),
consider positive ADTs definitive and use throat culture when ADTs are
negative (42%), ADT alone (13%), ADT and throat culture for all patients
with pharyngitis (5%), and no tests for GABHS performed (2%). Thirty-one
percent usually or always treated with antibiotics before test results were
available. Only 29% of these "early treaters" always discontinued
antibiotics when tests did not confirm the presence of group A
streptococci. The drug of choice for treatment was penicillin (73%);
another 26% preferred a derivative of penicillin, particularly amoxicillin.
Many pediatricians altered their management when a patient had recurrent
streptococcal pharyngitis. Nearly half of the respondents would use a
different antibiotic than they used for routine acute streptococcal
pharyngitis. They most often changed to erythromycin (25%), cefadroxil
(23%), or amoxicillin-clavulanate (20%). Follow-up throat culture was
obtained by 51% of pediatricians after treatment of recurrent streptococcal
pharyngitis. A patient with chronic carriage of GABHS and symptoms of
pharyngitis would be treated with an antibiotic by 84%; most (62%) would
use a penicillin. Other choices were cephalosporins (19%), erythromycin
(12%), clindamycin (3%), or rifampin plus penicillin (3%). Tonsillectomy
was recommended for symptomatic carriers by 31% of respondents. Carriers
without symptoms were less likely to be treated with antibiotics (23%) or
referred for tonsillectomy (21%). CONCLUSIONS: Most surveyed
board-certified pediatricians managed acute GABHS pharyngitis
appropriately, but 15% to 20% used diagnostic or treatment strategies that
are not recommended. There was lack of a consensus about the management of
recurrent GABHS pharyngitis and chronic carriage of GABHS.
