Aims and Objectives Paediatric GAS pharyngitis is common¹ and associated with chronic health complications. Antibiotic treatment decreases risk of complications.² Many cases of pharyngitis are viral, and most milder GAS cases self-resolve without complication; injudicious antibiotic use is associated with bacterial resistance.^{3 4} A spike in GAS infections in Winter 2022 increased investigation and antibiotic prescribing.⁵ Guidelines were produced to manage potential GAS pharyngitis in our ED, incorporating revised FeverPAIN score treatment thresholds.⁶ We audited adherence to determine impact on appropriate clinical management.

Method and Design We audited microbiology results, medical notes and antibiotic prescribing rates of patients presenting with symptoms of pharyngitis who received bacterial throat swab (BTS) testing - calculating FeverPAIN scores. We excluded <3 year-olds or provisional scarlet fever diagnoses. GAS-positive BTS were compared with associated FeverPAIN scores to calculate Positive Predictive Values (PPV), and corresponding antibiotic prescribing rates.

Results and Conclusion 21 BTS were sent in the 2 months pre-guideline (October – December 2022), and 137 BTS were sent in the 6 months post-guideline (December 2022 – June 2023). GAS positivity was 38.1% versus 33.6% respectively. Rates of GAS-positive patients receiving antibiotics on discharge decreased from 100.0% to 69.6% (p=0.077); all GAS-positive patients not given antibiotics on discharge were prescribed antibiotics after swab result. GAS-negative patients receiving antibiotics fell from 69.2% to 57.1% (p=0.543). FeverPAIN ≥4 had a PPV of 50% pre-guideline, whilst the post-guideline revised treatment threshold FeverPAIN ≥3 had PPV of 41.1%.

Whilst demonstrating good guideline adherence and targeted antibiotic prescribing post guideline introduction, this didn’t improve the correct identification and treatment of GAS. The FeverPAIN score PPV was low, meaning there were children who could have come to harm had BTS not been sent and results acted upon. This suggests reduced reliability of FeverPAIN scoring. With future spikes in GAS cases likely, further research needs to be done to correctly target antibiotic prescribing for GAS pharyngitis.

References

1. Martin JM, Green M. Group A streptococcus. Semin Pediatr Infect Dis. 2006;17(3):140-8.

2. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev. 2021;12(12):CD000023.

3. Dooling KL, Shapiro DJ, Van Beneden C, Hersh AL, Hicks LA. Overprescribing and inappropriate antibiotic selection for children with pharyngitis in the United States, 1997-2010. JAMA Pediatr. 2014;168(11):1073-4.

4. Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf. 2014;5(6):229-41.

5. Public Health Scotland. Group A Streptococcal Infections. 2023 [Accessed 22nd June 2023] https://www.hps.scot.nhs.uk/a-to-z-of-topics/streptococcal-infections/group-astreptococcal-infections/

6. NHS England. Group A streptococcus in children interim clinical guidance summary. 2022. [Accessed 22nd June 2023]