Background: Primary prevention of acute rheumatic fever requires antibiotic treatment of acute streptococcal pharyngitis. In developing countries, clinicians must rely on clinical guidelines for presumptive treatment of streptococcal pharyngitis since bacterial culture and rapid diagnostic tests are not feasible. We evaluated the WHO Acute Respiratory Infection guideline in a large urban paediatric clinic in Egypt.
Methods: Children between 2 and 13 years of age who had a sore throat and pharyngeal erythema were enrolled in the study. Clinical, historical, and demographic information was recorded and a throat culture for group A beta-haemolytic streptococci was done. Sensitivity (% of true-positive throat cultures) and specificity (% of true-negative throat cultures) were calculated for each clinical feature. The effect of various guidelines on correct presumptive treatment for throat-culture status was calculated.
Findings: Of 451 children with pharyngitis, 107 (24%) had group A beta-haemolytic streptococci on throat culture. A purulent exudate was seen in 22% (99/450) of these children and this sign was 31% sensitive and 81% specific for a positive culture. The WHO Acute Respiratory Infections (ARI) guidelines, which suggest treatment for pharyngeal exudate plus enlarged and tender cervical node, were 12% sensitive and 94% specific; 13/107 children with a positive throat culture would correctly receive antibiotics and 323/344 with a negative throat culture would, correctly, not receive antibiotics. Based on our data we propose a modified guideline whereby exudate or large cervical nodes would indicate antibiotic treatment, and this guideline would be 84% sensitive and 40% specific; 90/107 children with a positive throat culture would correctly receive antibiotics and 138/344 with a negative throat culture would, correctly, not receive antibiotics.
Interpretation: The WHO ARI clinical guideline has a high specificity but low sensitivity that limits the unnecessary use of antibiotics, but does not treat 88% of children with a positive streptococcal throat culture who are at risk of acute rheumatic fever. A modified guideline may be more useful in this population. Prospective studies of treatment guidelines from many regions are needed to assess their use since the frequency of pharyngitis varies.
PIP: In developing country settings without access to bacterial culture and rapid diagnostic tests, the prevention of acute rheumatic fever depends on clinicians' presumptive treatment of streptococcal pharyngitis. This study evaluated the effectiveness of World Health Organization (WHO) acute respiratory infection guidelines in a large pediatric clinic (Abu Reesh Children's Hospital) in Cairo, Egypt. 451 children 2-13 years of age with sore throat and pharyngeal erythema were enrolled, 107 (24%) of whom had group A beta-hemolytic streptococci on throat culture. Purulent exudate, present in 99 (22%) of these children, was 31% sensitive and 81% specific for a positive culture. The WHO guidelines, which recommend treatment for pharyngeal exudate plus enlarged and tender cervical node, were 12% sensitive and 94% specific. Based on these guidelines, 13 of 107 children with a positive throat culture would correctly receive antibiotics and 323 of 344 with a negative culture would not receive antibiotics. A modified guideline in which exudate or large cervical nodes would indicate antibiotic treatment would be 84% sensitive and 40% specific. With this modification, 90 of 107 children with a positive throat culture would correctly receive antibiotics and 138 out of 344 with a negative culture would not receive treatment. However, additional prospective studies from other regions of Egypt are necessary before modified guidelines are implemented.