Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic

Abstract

Background: The guidelines from the American College of Physicians and the Infectious Diseases Society of America differ with respect to the use of clinical criteria and microbiologic testing to identify adults with pharyngitis who are likely to have group A beta-hemolytic streptococci.

Methods: To measure the rate of adherence to 3 strategies, we performed a retrospective analysis of visits to Boston, Mass, area primary care clinics by adults with a diagnosis of pharyngitis (n = 2097).

Results: The 4-point Centor criteria recommended by the American College of Physicians and Infectious Diseases Society of America were not predictive of streptococcal testing (results for 0, 1, 2, 3, and 4 criteria were 79%, 81%, 79%, 80%, and 74%, respectively; P = .63) but were predictive of a positive streptococcal test (8%, 13%, 22%, 31%, and 30%, respectively; P<.001) and of antibiotic prescribing (25%, 34%, 63%, 80%, and 89%, respectively; P<.001). Clinicians were adherent to the American College of Physicians' empirical strategy in 12% of visits, the American College of Physicians' test strategy in 30% of visits, the Infectious Diseases Society of America's strategy in 30% of visits, and adherent to none of these strategies in 66% of visits. The most common reason for nonadherence to any strategy was testing or antibiotic prescribing to patients at low risk of streptococcal pharyngitis (1076 visits; 78% of the visits in which physicians were nonadherent to any strategy), patients for whom the guidelines agree.

Conclusions: The major problem in the testing and treatment of adults with pharyngitis is not which guideline to follow, but that clinicians usually fail to follow any guideline. Interventions should focus on an area where the guidelines agree: avoiding testing and antibiotic prescribing to patients at low risk for streptococcal pharyngitis.