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

BackgroundStratifying 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.MethodsA 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.ResultsA 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).ConclusionsIndividual 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.

[1]  W P LOGAN,et al.  Morbidity statistics from general practice. , 1954, The Practitioner.

[2]  J. Enders,et al.  Infectious Diseases Society of America. , 1969, Antimicrobial agents and chemotherapy.

[3]  W. R. Maxted,et al.  Streptococcal pharyngitis in the general population. II. The attack rate of rheumatic fever and acute glomerulonephritis in patients. , 1971, The Journal of infectious diseases.

[4]  R. C. Johnson,et al.  Recognition of streptococcal pharyngitis in adults. , 1975, Archives of internal medicine.

[5]  B. Breese,et al.  A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. , 1977, American journal of diseases of children.

[6]  R M Centor,et al.  The Diagnosis of Strep Throat in Adults in the Emergency Room , 1981, Medical decision making : an international journal of the Society for Medical Decision Making.

[7]  P. Heckerling,et al.  Streptococcal pharyngitis in an adult emergency room population. , 1985, The Journal of family practice.

[8]  W. Parsons,et al.  Diagnosis and treatment of streptococcal pharyngitis. , 1985, JAMA.

[9]  R D Cebul,et al.  The importance of disease prevalence in transporting clinical prediction rules. The case of streptococcal pharyngitis. , 1986, Annals of internal medicine.

[10]  R S Wigton,et al.  Transportability of a decision rule for the diagnosis of streptococcal pharyngitis. , 1986, Archives of internal medicine.

[11]  J M Scheller,et al.  The rational clinical examination. , 1992, JAMA.

[12]  Neal Devitt,et al.  The rational clinical examination. , 1992, JAMA.

[13]  M. Kljakovic.  Sore throat presentation and management in general practice. , 1993, The New Zealand medical journal.

[14]  R. Robinson.  Economic Evaluation and Health Care Cost-effectiveness analysis , 2006 .

[15]  R. Skjaerven,et al.  Assessment of clinical features predicting streptococcal pharyngitis. , 1993, Scandinavian journal of infectious diseases.

[16]  P. Saikku,et al.  Clinical scoring system in the evaluation of adult pharyngitis. , 1993, Archives of otolaryngology--head & neck surgery.

[17]  Dwight R. Johnson,et al.  Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. , 1993, Pediatrics.

[18]  Diagnosis and treatment of streptococcal sore throat , 1995, Drug and therapeutics bulletin.

[19]  D E Low,et al.  A clinical score to reduce unnecessary antibiotic use in patients with sore throat. , 1998, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[20]  Sore throat: diagnostic and therapeutic dilemmas , 1999, BMJ.

[21]  T. To,et al.  The validity of a sore throat score in family practice. , 2000, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[22]  Mark H. Ebell,et al.  Does This Patient Have Strep Throat , 2000 .

[23]  M H Ebell,et al.  The rational clinical examination. Does this patient have strep throat? , 2000, JAMA.

[24]  P. Glasziou,et al.  Antibiotics for sore throat. , 2013, Nursing times.

[25]  R. Stafford,et al.  Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. , 2001, JAMA.

[26]  Vincenza Snow,et al.  Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults , 2001, Annals of Internal Medicine.

[27]  J. Roberts,et al.  Acute pharyngitis. , 2020, The New England journal of medicine.

[28]  Yvonne Vergouwe,et al.  Validity of prognostic models: when is a model clinically useful? , 2002, Seminars in urologic oncology.

[29]  M. Gulich,et al.  Development and validation of a simple, two-step algorithm to identify streptococcal infection in adults with sore throat , 2002 .

[30]  T. To,et al.  Effect on antibiotic prescribing of repeated clinical prompts to use a sore throat score: lessons from a failed community intervention study. , 2002, The Journal of family practice.

[31]  W. McIsaac,et al.  Diagnosing streptococcal pharyngitis in the emergency department: Is a sore throat score approach better than rapid streptococcal antigen testing? , 2002, CJEM.

[32]  A. Bisno,et al.  Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. , 2002, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[33]  M. Aronson,et al.  Diagnosis and Management of Adults with Pharyngitis: A Cost-Effectiveness Analysis , 2003, Annals of Internal Medicine.

[34]  R. Raz,et al.  Clinical predictors of streptococcal pharyngitis in adults. , 2003, The Israel Medical Association journal : IMAJ.

[35]  R. Brian Haynes,et al.  Developing Optimal Search Strategies for Detecting Sound Clinical Prediction Studies in MEDLINE , 2003, AMIA.

[36]  N. Månsson,et al.  Rapid test, throat culture and clinical assessment in the diagnosis of tonsillitis. , 2003, Family practice.

[37]  P. Bossuyt,et al.  BMC Medical Research Methodology , 2002 .

[38]  Warren J McIsaac,et al.  Empirical validation of guidelines for the management of pharyngitis in children and adults. , 2004, JAMA.

[39]  Michael A. Gerber,et al.  Rapid Diagnosis of Pharyngitis Caused by Group A Streptococci , 2004, Clinical Microbiology Reviews.

[40]  Diagnosis and Management of Adults with Pharyngitis , 2004 .

[41]  P. Glasziou,et al.  Antibiotics for sore throat. , 2004, The Cochrane database of systematic reviews.

[42]  H. Mcdonald,et al.  Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. , 2005, JAMA.

[43]  P. Hjortdahl,et al.  Clinical symptoms and signs in sore throat patients with large colony variant beta-haemolytic streptococci groups C or G versus group A. , 2005, The British journal of general practice : the journal of the Royal College of General Practitioners.

[44]  M. Barry,et al.  Brief report: The role of point of care testing for patients with acute pharyngitis , 2005, Journal of General Internal Medicine.

[45]  Kenneth F Schulz,et al.  Refining clinical diagnosis with likelihood ratios , 2005, The Lancet.

[46]  [Short communication: clinical predictors of group A beta hemolytic streptococci isolation in upper respiratory tract infections]. , 2005, Mikrobiyoloji bulteni.

[47]  Johannes B Reitsma,et al.  Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. , 2005, Journal of clinical epidemiology.

[48]  S. Tiengrim,et al.  Upper respiratory tract infection in Thai adults: prevalence and prediction of bacterial causes, and effectiveness of using clinical practice guidelines. , 2006, Journal of the Medical Association of Thailand = Chotmaihet thangphaet.

[49]  P. Bossuyt,et al.  Use of methodological search filters to identify diagnostic accuracy studies can lead to the omission of relevant studies. , 2006, Journal of clinical epidemiology.

[50]  T Fahey,et al.  Accuracy and impact of risk assessment in the primary prevention of cardiovascular disease: a systematic review , 2006, Heart.

[51]  P. Bovier,et al.  Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings. , 2006, Archives of internal medicine.

[52]  D. Bates,et al.  Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic. , 2006, Archives of internal medicine.

[53]  P. Glasziou,et al.  Antibiotics for sore throat (Review) , 2006 .

[54]  P. Wludyka,et al.  Throat Culture Is Necessary After Negative Rapid Antigen Detection Tests , 2007, Clinical pediatrics.

[55]  Joseph Griffiths,et al.  Diagnosing streptococcal sore throat in adults: randomized controlled trial of in-office aids. , 2007, Canadian family physician Medecin de famille canadien.

[56]  Rapid diagnosis of streptococcal pharyngitis in adult emergency room patients , 1986, Journal of General Internal Medicine.

[57]  A. Komaroff,et al.  The prediction of streptococcal pharyngitis in adults , 2007, Journal of General Internal Medicine.

[58]  T Fahey,et al.  Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis. , 2006, QJM : monthly journal of the Association of Physicians.

[59]  L. Benito Ortiz,et al.  [Is streptococcal pharyngitis diagnosis possible?]. , 2007, Atencion primaria.

[60]  J. D. L. Iglesia,et al.  Es posible el diagnstico clnico de la faringoamigdalitis estreptoccica , 2007 .

[61]  C. Llor,et al.  [Validation of a rapid antigenic test in the diagnosis of pharyngitis caused by group a beta-haemolytic Streptococcus]. , 2008, Atencion primaria.

[62]  S. Anadón,et al.  Validación de una técnica antigénica rápida en el diagnóstico de la faringitis por estreptococo betahemolítico del grupo A , 2008 .

[63]  H. Benzon,et al.  Evidence-Based Case Report: The Prevention and Management of Postherpetic Neuralgia With Emphasis on Interventional Procedures , 2008, Regional Anesthesia & Pain Medicine.

[64]  A. Hoes,et al.  Predicting death in elderly patients with community-acquired pneumonia: a prospective validation study reevaluating the CRB-65 severity assessment tool. , 2008, Archives of internal medicine.

[65]  B. Arroll,et al.  Guidelines for sore throat management in New Zealand. , 2009, The New Zealand medical journal.

[66]  Penny Whiting,et al.  Metandi: Meta-analysis of Diagnostic Accuracy Using Hierarchical Logistic Regression , 2009 .

[67]  A. Garg,et al.  Diagnostic test systematic reviews: bibliographic search filters ("Clinical Queries") for diagnostic accuracy studies perform well. , 2009, Journal of clinical epidemiology.

[68]  F. Wood,et al.  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 , 2009, BMJ : British Medical Journal.

[69]  D. Moher,et al.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement , 2009, BMJ.

[70]  D. Moher,et al.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. , 2010, International journal of surgery.