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Acute pharyngitis in children

BIBLIOGRAPHIC SOURCE(S)
Michigan Quality Improvement Consortium. Acute pharyngitis in children. Southfield (MI): Michigan Quality Improvement Consortium; 2004 Apr. 1 p.
GUIDELINE STATUS
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.
RECOMMENDATIONS
MAJOR RECOMMENDATIONS
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline. The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Facts

60 to 75% of pharyngitis cases in children are viral [C].
The reason to treat Group A beta hemolytic Streptococcus (GABHS) is to decrease the risk of rheumatic fever [A].
Presenting signs and symptoms can be used to determine the probability of GABHS.
Confirm all negative rapid strep screens with a throat culture [C].
A 10-day course of oral antibiotics is necessary.
Assessment

Assess past history of rheumatic fever (especially carditis/valvular disease) or household contact with a history of rheumatic fever to identify high risk patients.

If non-high risk, assess the likelihood of strep pharyngitis using the following six items--score 1 point if present:

Absence of cough, rhinorrhea, and conjunctivitis
Fever at least 38.3 degrees Celsius (100.9 degrees Fahrenheit) within last 24 hours
Age 5 to 15 years
Erythema, swelling, or exudates of tonsils or pharynx
Tender anterior cervical nodes = 1cm
Season is November to May [C]
Diagnosis

High Risk Patients

Start antibiotics immediately. If throat culture (TC) is obtained and is negative, stop antibiotics.

Non-High Risk Patients

Points: 0-1

Probability of GABHS: Low
Testing: None
Treatment: Symptomatic treatment only. Avoid antibiotics.

Points 2-4

Probability of GABHS: Intermediate
Testing: TC OR Rapid Screen (only use if immediate diagnosis is required1)
Treatment:
If TC positive -- antibiotics; if TC negative -- symptomatic treatment only. Avoid antibiotics.
If Rapid Screen positive -- antibiotics; if Rapid Screen negative -- culture and only use antibiotics if throat culture is positive.

Points 5-6

Probability of GABHS: High
Testing: None (only use culture or Rapid Screen if there is a need to confirm diagnosis1)
Treatment: Start antibiotics immediately. If throat culture is obtained and is negative, stop antibiotics.

1E.G., to document an index case to treat symptomatic close contacts rapidly or if antibiotics fail

Treatment

Preferred Treatment for Strep Pharyngitis

Penicillin VK: 250 to 500 mg twice or three times daily (bid-tid) x 10 days
Amoxicillin: 20 to 40 mg/kg/day divided tid x 10 days [A]
Benzathine Penicillin G intramuscularly (IM) x 1: 600,000 units for weight <60 lbs; 1.2 million units for weight >60 lbs
If Penicillin allergic: Erythromycin Ethyl Succinate (EES): 40 mg/kg/day bid-four times daily (qid) (max 1 g/day) x 10 days; or Erythromycin Estolate: 20 to 40 mg/kg/day bid-qid (max 1 g/day) x 10 days
Alternative Treatment for Strep Pharyngitis

Cephalexin 15 to 50 mg/kg/day divided bid or tid x 10 days
Re-Evaluate/Referral

If failure to respond clinically after 48 hours of treatment, rule out peritonsillar or retropharyngeal abscess. If present, prompt otolaryngology (ENT) evaluation is recommended.
Assess the potential for a compliance problem.
Definitions:

Levels of Evidence for the Most Significant Recommendation

Randomized controlled trials
Controlled trials, no randomization
Observational studies
Opinion of expert panel
CLINICAL ALGORITHM(S)
None provided


EVIDENCE SUPPORTING THE RECOMMENDATIONS
TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS
The type of evidence is provided for the most significant recommendations (see "Major Recommendations" field).

This guideline is based on several sources, including: the ICSI Acute Pharyngitis Guideline, Institute for Clinical Systems Improvement, 2001 (www.icsi.org).

IDENTIFYING INFORMATION AND AVAILABILITY
BIBLIOGRAPHIC SOURCE(S)
Michigan Quality Improvement Consortium. Acute pharyngitis in children. Southfield (MI): Michigan Quality Improvement Consortium; 2004 Apr. 1 p.
ADAPTATION
This guideline is based on several sources including, the ICSI Acute Pharyngitis Guideline, Institute for Clinical Systems Improvement, 2001 (www.icsi.org).

DATE RELEASED
2004 Apr

GUIDELINE DEVELOPER(S)
Michigan Quality Improvement Consortium

SOURCE(S) OF FUNDING
Michigan Quality Improvement Consortium

GUIDELINE COMMITTEE
Michigan Quality Improvement Consortium Medical Director's Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE
Physician representatives from participating Michigan Quality Improvement Consortium health plans, Michigan State Medical Society, Michigan Osteopathic Association, Michigan Association of Health Plans, Michigan Department of Community Health, and Michigan Peer Review Organization

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST
Not stated

GUIDELINE STATUS
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

GUIDELINE AVAILABILITY
Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the Michigan Quality Improvement Consortium Web site.

AVAILABILITY OF COMPANION DOCUMENTS
None available

PATIENT RESOURCES
None available

NGC STATUS
This NGC summary was completed by ECRI on November 28, 2005. The updated information was verified by the guideline developer on December 19, 2005.

COPYRIGHT STATEMENT
This NGC summary is based on the original guideline, which may be reproduced with the citation developed by the Michigan Quality Improvement Consortium.

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