CLINICAL PRACTICE GUIDELINES MOH/P/PAK/68.03 (GU) ACADEMY OF eee inrecnovs Beexses HEALTHMALAYSIA. MEDICINE OF Mataysia'NFECTIO APRIL 2003,FOREWORD ‘Sore throat is inevitably one of the most common symptoms experienced by people at one time or anctner As thare are many causes of sare throats ite Impartant hat the modiea practioner be familiar withthe possbi'bes so tat he best evidence-based veatment can de offered to the patent As infective {halogies of sore throat are arguably among the most common causes of sore throat and mth widespread inudieious antrcrobal therapy for sore thvoat inthe Community, there is @ danger af increasing antmicrobia resistance ang untoward Sie effocts of therapy. Furhermare.agcurste cinical ciagnos of the most Common infective pathogen for sore oat Le. Group A Stvepoeaccus, Is often Gifeut to eslabish Diagnostic faites for accurate detecton ofthis particular ‘organism are ofl lacking and results are ollon delayed in most amuatory practices, compounding the difleates in accurate diagnosis and aporograte ‘management. Also, fonsilactomy has ofsn been reconmardied fr patents with Fecurret sore throat athaugh the incieations may be questionable his wih this ‘multfacoted background that 3 working group was commissionec fo formulate @ Cinial practice guideline (CPG) on the management of sore throat ih nique rence to Grou A Streptococcal pharyngis because iis the most common bacterial cause of sore troat where resins ingicated. 1s Ropes that this (CPG willbe able to acdrass sore of these issues anc met the needs ofthe medical practioner towards managing this common symptom. Final | would like to abxnowledge the fervent suppor ofthe Malaysian Society of Infectious Diseases & Chemotherapy and Pharmacia Malaysia for excellent secretarial, assistance ane pubicaton ofthis document. De Tan Kah Keo: ChatmanCLINICAL PRACTICE GUIDELINES DEVELOPMENT GROUP DrTan Kah Kee (Chairman) Pact infectious Disease Consultant Department of Pedaties Seremban Hospital Prof Dr Christina Tan Dept of Pimary Care University Malaya Medical Cente, Kuala Lumpur Dr Christopner Loe Infectious Disease Consutant Department of Nese Hospital Kuala Lumpur De Davis Manickam Consuitant Pediatrician oh Speciatst Center, ipoh AlProf MT Koh Posiatic ID Consutant Departrart of Pediatrics University Malaya Medical Centre, Kuala Lumpur Dr Koh Tat New. Consultant ENT Surgeon Department of Ororinolanngotogy University Malaya Medica! Cantre, Kuala Lumpur Dr Sobani Dia Consultant ENT Surgeon eoartment of im nolaryagology Selayang Hospital Dr Tan Lian Huet Consultant Physician Infectious Disease Unit University Malaya Medical Cente, Kuala LumpurGUIDELINE DEVELOPMENT AND OBJECTIVES Guideline Developme: Sore thoet is 8 very common symatam in both children and adults. caused by many etiooges including infections due to bacterial end vial pathogens. 1s Sia a conenon cause of presentation to motel practitioners. Sore tnvoatis & frequent indication of anbiole. preseripion im the community, resulting in Significant healthcare costs. and may. potentially contribute to increasing fnlimicrobal resislance win widespread and snappropiate use of anvbiotis Furtnermore, tonsilectony Is offen recommenced ungustably for patients ith fecurrent sore thraat although the outcome is as yel undetined, and may oientlly cause apprecabie morbiiy in some patents. Sore thvoat in tis {urdelne veers to both fonsliis anc pharyngitis or Both, occuring in the context of nfecton Objectives ‘The main aim ofthe guideline isto present evidence based recommendations to assist medical practitioners in providing a atonal approach inthe management Gf sore tioat and also would ghight the need fo ratonal anc judicious use of “Snabitics in is managamort Clinical Question ‘The cineal questions of these guidelines are |. What isthe rational approach to the management of sore theo in {he communty? 4. Whats. reasonable entero to refer cases for onsilectomy? Target Population “These guidelines are to be appled to bath paodiarc and adult patents from the community lh complaints a sore throat ‘Target Group ‘These guidelines are developed for al health care professionals iovolved inthe agnosis and management of cases wih sore toa,LEVELS OF EVIDENCE SCALE [1] Evidence obtained trom at Teast one propery randomized controlled — ‘nal [TET Bienes obtained rom war aosiged conrated tals wiraut randomeation [7-2 Evidence Stained from well-designed cohort o case-control analy ‘Sluces, preferably rom more than one center or fesearen group | "W=3 eicence eosin Fam up to Sos wih or witout he | intervention, Oramatic results in uncontrolled experiments (such as | the results ofthe introduction of penclin treatment in he 1640s) could also be regarded as this typeof evidence WT Oprvons of respected autores, based on ical experience descriptive sucies and case reports: o ports of expert commitaes SOURCE: US. / CANADIAN PREVENTIVE SERVICES TASK FORCETABLE OF CONTENTS Foreword inca) Practice Guidelines Development Group Guidetne Dovolopment And Odjecives Levels OF evidence INTRODUCTION 1.1 Epioemiology 112Eeonome Cost CLINICAL MANIFESTATIONS OF SORE THROAT DIAGNOSIS AND LABORATORY INVESTIGATIONS 341 Laboratory dlagnosis 3.2 Specimen callaction 53.3 Specimen anspor and storage 34 Spacimen processing 35 Atmosphere of cubation 38 Rapid Antigen Detection Tests (RADT) 437 Recommendations for éiagnosss COMPLICATIONS MANAGEMENT 5.1 Symptomatic treatment 5.2 Amibiotc nrapy for GABHS charyngis 5.21 Antbiatics for streptococcal sore throat: Paedlatne Age Group 5.22 Anite for streptococcal sore throat: Acts 53 Surgical teaiment ALGORITHN FOR MANAGEMENT OF SORE THROAT REFERENCES+ wrropuctioN 14 Epidemiotogy ‘The epidemiology of sore throats in Malaysia with respec tots prevalence, age- specie incidence, aetology and complications hes not been wall studied and documented. in a 1884 hospta-basea study involving tree general nosptls in Kuala Lumous, Kota Baru and poh. acute respiratory infections (ARs) wers responsite fr 44.11% ofall paediatric admissions (1) Ina later study in 1996, Ihe prevalence for ARIs in he preceding 2woexs in chidren below & years was 38.3 %, of whch 91% of te cases were upper respiratory tract infactons (URTI) Although the prevaience of tonsiflopnaryngits im. these studies a3 not \decumented, undoubtedly URTI is. the most common reason for seeking {teatment in general practee and hospta ouipatient departments (2.3) Epidemiological data teom Westem counties on sore thvoat in general and specifeally Group A f-nemolytle Steplecoccus (GABHS) infectone , both conmunity and hospital-based, are more raadly avaiable. However there Is considerable variation into provalence of GABHS sore throats from one county to another (4-9), bot in Asian and Wester countries For example. in Dhaka 28 56 of 601 chidron studied hac @ positive culture txt only 2.2% is cue to GABHS. In Israel the provalance is 15 % among 752 symetomaticchidren aged 3 month 1 5 years old Inthe italan-Freneh study 28% of 885 chideen from 5 monins fo 14 years had GABHS pharyngils. Over the igure i less Than 20 Sein most courines. inthe adult population GABHS Is vesponsible for 10% of cases ol ‘2eute pharynais (8,10). 1.2 Economic cost ‘The economic impact of pharyngitis local is not known due to paucity of studies, although this hes been studied in same Wester counties. In the adul population, about 6.7 milion visits annually to a meal practioner were for sore ‘oat (12. nthe UK i's estimated that vies Yor canautation for sore twoat ‘alone (btore any invesigation or eatment) cast the NHS £80 milion per anim (18), Consequently, treating. pharyngiis in bath enidfen and aduls has Significant economse ang neath impact 2. CLINICAL MANIFESTATIONS OF SORE THROAT ‘The etologe agents of sore throat ate listed in Table # (14) Viral pathogens are more frequent causes af nective sore throal compara to bacterial pahwoyens GABHS isthe mast common dacteral cause of acute pharyngils. accounting for approximately 15-30% of cases in children ana Is also the only common form of phanmnais for which anubiate terapy is indicated (@ 18). Streptococcal sore throat 's usualy rare in chloren <3 years, Occuring more frequenty in children between 5-18 years ala (8). Symptoms and signs of GABHS pharyngits are larly Simla in chldren and adults. Syrptoms include sudden onset of sore treat, pain on swallowing, fever, headache, abcominel pain, nausea and vorvtng. ‘Signs incude tonsilopharyngeal eryinema, tonsilopharyngeal exxdate sf palale petechise; beol-red swollen Wula, swollen and fender anterior cervicalIymph nodes and rash (2). Not all patents nave the ullbiown synctome and ‘many cases are mide: anc co not have exudates. ae emai a ' PBhnowas 2» Seeeatts |. eine ° | Poe ue : teers a eee A Epes Q cremate 4 i “i fal - ‘590 —. : a § ee Senciscoum teroius St hye enuronse own — a + Adopted from Gwaltney JM etal (14) Prevalence of GAS pharyngitis i signcanti ower in 5-108 of eases (2), A razert study in Hong Kong reve in those > 14 year of age (17). In bath chien and adults the vsual incubation Datiod for streptococcal poral is 2-5 days (18) ‘The clinical picture n adults charecterized by an abrupt onset of te following Sore foal associated with aficuty in swallowing + Fever moderato (33-40 5°) Chil maybe present out igors rare + Malaise 2 Headache Gl symptoms: anorexa, nausea, vomiting & abdominal pains (35-50% of tases) aut not veries by objective stuces, Rhinorhea, cough, hoarseness, conjunctivitis, and dianhea are typeally not Seen in steptocaccal infection, emg more offen sean in infectons of viral ‘etioiogy (8.18) Homever ner is abroad overap inte crical presentation of Streptococcal and vial pharyngits making it dificult cinically to differentiate DDetween them, Some of these “eatures have been used as a form of clinical {sooring (one of whien Is eescrinee bolo) to assist clnicans in making a linical iagnosis of GABHS pharyngitis (20-22),‘A scoring systom has been devised by Melsaac'o increase tne nical agnostic ‘ccaracy . based on age and four sinical symptoms 8 tonsilar sweling / ‘exudates, swollen anterar corvical nodes, fever > 38°C & lack of a cough (22), Even ia patient has all four classic symptoms, there i @ significant probability that tis not Group A stptococea! sore throsl, Howaver «presence of certain Clinical festures such ag thmnormhea hoarseness cough, eonuncivis area land oropharyngeal uleration may suggest a likely vial evology (8.19.23), 3. DIAGNOSIS AND LABORATORY INVESTIGATIONS, [As the precise clinical diagnosis of GABHS phannatis ‘= cificut it Is recommended that the cinigians decision 1 perfarm a laboratory tet for @ Patent with suspected GABHS pharyngils be. bases on the Mclssae scorng ‘system (Esiconoe love I-2)22) This system altenps fo predic the probably thatthe pharyngitis is caused by GABHS. Hence, testing need not be performed for patents win acute pharyngitis whose elnical and epdemvolagcal features do not suggest GABHS infection As Glagnosis of group A sireptacoccal paris Cannot be confcenly excuded, Dactsrcloge studies. should be performed ‘uided by this scorng systom (Evidence level 12}. Selecive use of the Suggested diagnostic est Tor group A streptococa wil sul in an increase in bath the proportion of postive Tost resus and tne prcentage of patents wth positive tst wna are truly infectee than are merely cariers(Evisenee level 2), Methods for the diagnosis of group A steplococcal pharyngitis are Dased on ecommendations ftom the Pubic Heath Laboratory Service Standard Operating PPracedure on invesigaton of Throat Swabs (24) and he guideline on siagrasie of GAS pharyngitis by the Infecigus Diseases Society af Americ (25). 3.4 Laboratory diagnosis Culture of throat swab forthe presence of GABHS remains the gold standard for the confirmation of the cinal diagnose of acute streptococcal pharyng is (Evidence tevel 112). A single throat swab coleces, Vansporied and cultured lnder recommenced conditans has a sensitily of 80%-95% In detecting the presence of group A stepiococcus inthe pharynx. Vatiatons in the ealletion ‘vanspor and culture matnods can affect the accuracy of tha cuture results, 2:2 Specimen collection ‘Tat swab specimens must be oblained from surface ofboth the tonsils and the posterior pharyngeal wall. The mouth, uvula and oropharynx are not ‘acceptable sites for sampling and tne swab should nat be contaminated by touching these sites before o” after the sampling process. Manner in which the swab is obtained has.an impact on the yeld af sreptococc! from the toat {uur (26, 27), Optimal me of speciran coliecion Isat the anset of symptoms ‘and botore amimirobaltnerany = statedheating the loop. final inoculation wat the oop Is done with several stabs ito the ager to allow observation of subsurface haemolysis: Some sisi of group A sreplococei ere haemolytic only under conditions of reduced oxygen iension. Detection of Sreptococeus pyogenes trom culture plate ie based on typica) of theacer OF Sone OAT 3.5. Atmosphere of incubation ‘The culture plates are then incubated st 35°C 37°C for 18 -24h, aorobicaly, before they are read. Additonal averight incubation at room emperature slows ‘doniication ofa considerable number of postive throat cultures (24), Therefore, ‘X's recommended that pates which are negative during the frst 24 hours are eoxamined at 48 hours for growth resembling group A bela-heemolyic ‘Sveptococc!, Any colonies usvally loss than mm in giometer grey-white of colourless wih beta-haemolyss, dr or shiny and usualy wh an regular outine 's suggestive of group A streptococcus (Figure 2). Not _stropiococa are Lancafielé group A therefore dferentation of group A fom ‘on-graup A strains should bo accomplished as stated below. Pee emt np on pn ‘Sensitivity to bactracn (using a 0,004u dec) ie used to assist nth Kentfeation| ‘of group A steptococs, Ths test provides a prosumpiive Weriicaton based on the observation that more than 85% of group A streptococ! show a zone of Jnhbton around a disc of bactracin Figure 3) while B0¥-87% of non-group A ‘streptocoeo donot (0,31),‘A highly specitc metiod (82) for identiying group A staptococe Ia by the {otecton of group speci cll wall carbohydrate antigen drecty from bacteria) futures (Figure 4) . using group specific antiserum which are obtained commercial. ee rhs tp ct st en Song Austen Ceara ro A sec) Svacsetetee Mean 3.8 Rapid Antigon Detection Tests ( RADT) ‘ith he aveiaiy of RADT (Figure 5). group A streptocacci can be dented 2Tkg 1,200,000 units x 7 dose For patients allergic to peniciie ‘erythromycin stolate:20-40mg/kgidaybid-gd max, 1giday) x 10 days cenjtomyein ethysuccinate:4Omgkaléay bid (max. 19/ay} x 10 days For patients alergic to pencilin & alsa erthromycin-intolerant: Clindarycin: 20-20 ma/kgiday bd x 10 days Clinical response of chitren with Group A streptococcal phanngiis to ‘propriate antimicrobial therapy is usually euident within 24-48 hours Porsistence of symptoms beyend 48 hours may incicae altsnaive causes such {8 viral pharyngiis, dovelonment of supguratve complations such ae Pettonslar abscess and warrant reassessment. Recutrence of acule Streptococcal pharyngis folowing a couree of antbiatic tery may be due to inappropriata anbiote therapy (e 9. cotimoxazaie) inadequate dove or craton of provious therapy, non-compliance and co-pathogenely by betalactamase: producing organisms (18). Therapy with invamuseuar Beneathine penelin (Evidence level |) (62) clindamycin (Eugence tvell-t) (63-65), arponyiln- clavulanate (Evidence level I-t) (66) and cefuroxime (Evleance level I) (67) may be beneficial n these cases. Although broacer spectrum ora) antibiotics Such as second and thd generation cephalosporins and newer macrolides {demonstrate bath clnical and bactercogie efficacy, emergence of animrobial resistance and nigh cost are practical concerns (18, 68)[cute pharyngts (sore throat (8 ono of the most requent linesses seen at primary care level Alhough the group A streptococcus is the most common Dactoral cause of acute pharyngits, only a smal percentage of patients with tis Condition ae infected by group A sieptecocc.. The majoiy of sore throats are ‘alin nature. Antibes confer relative Benefits in the treatment of sore Host However, the absolut berets are mosest (Evidence ive) (69). ‘Group A streptococcal pharyngitis the only commonly occuring fom of acute [haryngts for which antibiotic therapy is definitly indicated (19). Antibiotics educe the incidence of bath suppurative and ron-suppuraive complications of Sore throat (70). Therelore, for @ patient with acute pharyngis, the clinical Gecision mat usualy needs to Oe made is whether the phenaits is atbutable togroup A streptocaca ations with acuta streptococcal pharyngitis should receive therapy with an fanimirobial agant in oe0 and for 2 duration thal is Iikely to eradicate the infecting organsm fom the pharynx. A number of anibiates have been shown to be effecive in treating group A streptococcal pharyngitis. These include Deniciin ond semi synthetic penlin's,ampilin and amoxycilin, as well 96 ‘umeraus cephalosporins and macrolides an cingamycin, [As in children. pericili remains the drug of choice because of its proven cficacy, safety, narrow spectrum, and is low cost. Phenoxymathypeniilin oF bericin V, 250 mg tid. org id (Evidence fev! I-1) oF 500 me Di-clevidence eve! Ih recommended for 10 days(71), Snorer weatmenteraciates GAS less ‘flecively and cinicl recurrence tvel's more common (Ewdence tve! | (72: 73) Erythromycin is suitable alternative for patients allergic to poncilin (in four times aly or twoe dally dosage)Evidence level 1-2). Howaver, unwanted ‘gastrointestinal etfects are common. Newer macrolides such a5 canthramyoin cause fower unwanted side effects but are expensive and no more effective ‘gaia! resistant stains, Fst generation cephalosporins are also acceplaba for patients allergic (0 peniin and who donot. manfest inmediate-type ypersansitviy to lactam antbiotis. For the rare patent infected with an erytnromycin-esistant stain of group A Streptococcus who is unable fo tolerate factam antibiotics, cindaryein is an ‘appropiate ateratve. 53. Surgical treatment ‘There are four randomized controled tials (RCT) on tonsillectomy versus ron surgical intrvention stucies in children (74-78) but ne RCT in aculs. Scottish interolegiate. Guidelines Network advised more than 5 episodes (47) and ‘American Academy of Otolaryngology more than 3 episodes. as indication for {onslectomy (74) Noncontraled studies demonetates fecuction in numer of sore threats and improved goneral heath wth torsctomy (78-81), woIndication for tonsilectomy are recurrent tonsils and pectonsilar abscess or auinsy that lis felioning ere: 1) Recurrent tonsils i) The symptom of sore throat is cue to inlarmation ofthe toni |) >Gepsodes of tnsltis aver a 12-manth panos, |i) uration of symptoms should be over a 12-month peri. Iv) The symptoms intrfece withthe patent's normal daly function AL the above crileria must be met before tonsllecomy is performed for recurent tonsils (vigonce lve! I), ») Penitonsilar abscess or quinsy |) Tonsllectomy indicated when the abscess has ‘failed to respond ta anpropriale aniboics togetner wth inion end tainage. This is farely required (Evidence lev! Il) Is an accepted surgieal practice thatall abscesses should be draines, ii) Tonsillectomy is nical f pallens develep quingy ane has a history of recurrent tonslits (Evidence level il) (82-87). Monever. one episode oF quinsy and ne signfeant histry of tonsils Is not an Inaleation fr surgery.6, ALGORITHM FOR MANAGEMENT OF SORE THROAT Malsaae score * Fever> = 98°C (+1) + No cough (+t) inical features: + Tonsilar exuctes (+4) * Rhints ‘+ Tender anterior cervical + Hoarseness ‘odes (+1) + Cough + Age «15 (+1) + Conunctvits + Dianhea + Gropharyngeat | — = [=] [Reermendice | | LT se oraiognoate | Vira etotogy hey |g LS 4 Eira | we fret an 5S ootected | initiate antibrotic __» ee (ee mien | [ Symptomate Yes Treatment a Treat with appropriate =) antibiotics (eer guidelines ———— ‘No eine response ater 48 nours | Reassess and consider underivng factors e9.vral. suppurative amplicons roneomplianes7. REFERENCES 1. 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