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Results by criteria, Group 4 baseline analysis.
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Figure 6: Results by criteria, Group 4 baseline analysis.

Mentions: For patients with a Centor score of 4, RAPID STREP & CULTURE is again the best management strategy with a priority score 22.0%. It is 1.06 times better than EMPIRIC TREATMENT (priority score 20.7%), 1.12 times better than CULTURE (priority score 19.6%), 1.16 times better than RAPID STREP (priority score 18.9%) and 1.17 times better than NO TEST, NO TREAT (priority score 18.8%). As shown in Figure 6, the main advantage of RAPID STREP & CULTURE in this situation is its ability to both prevent complications and promote optimal antibiotic use.

Optimal management of adults with pharyngitis – a multi-criteria decision analysis

Singh S, Dolan JG, Centor RM - BMC Med Inform Decis Mak (2006)

Bottom Line: We defined optimal patient management using four criteria: 1) reduce symptom duration; 2) prevent infectious complications, local and systemic; 3) minimize antibiotic side effects, minor and anaphylaxis; and 4) achieve prudent use of antibiotics, avoiding both over-use and under-use.Using the baseline assumptions, no testing and no treatment is preferred for patients with Centor scores of 1; two strategies--culture and treat if positive and rapid strep with culture of negative results--are equally preferable for patients with Centor scores of 2; and rapid strep with culture of negative results is the best management strategy for patients with Centor scores 3 or 4.These results are sensitive to the priorities assigned to the decision criteria, especially avoiding over-use versus under-use of antibiotics, and the population prevalence of Group A streptococcal pharyngitis.

Affiliation: Department of Medicine, Wake Forest University, Winston Salem, NC, USA. sosingh@wfubmc.edu

ABSTRACT

Background: Current practice guidelines offer different management recommendations for adults presenting with a sore throat. The key issue is the extent to which the clinical likelihood of a Group A streptococcal infection should affect patient management decisions. To help resolve this issue, we conducted a multi-criteria decision analysis using the Analytic Hierarchy Process.

Methods: We defined optimal patient management using four criteria: 1) reduce symptom duration; 2) prevent infectious complications, local and systemic; 3) minimize antibiotic side effects, minor and anaphylaxis; and 4) achieve prudent use of antibiotics, avoiding both over-use and under-use. In our baseline analysis we assumed that all criteria and sub-criteria were equally important except minimizing anaphylactic side effects, which was judged very strongly more important than minimizing minor side effects. Management strategies included: a) No test, No treatment; b) Perform a rapid strep test and treat if positive; c) Perform a throat culture and treat if positive; d) Perform a rapid strep test and treat if positive; if negative obtain a throat culture and treat if positive; and e) treat without further tests. We defined four scenarios based on the likelihood of group A streptococcal infection using the Centor score, a well-validated clinical index. Published data were used to estimate the likelihoods of clinical outcomes and the test operating characteristics of the rapid strep test and throat culture for identifying group A streptococcal infections.

Results: Using the baseline assumptions, no testing and no treatment is preferred for patients with Centor scores of 1; two strategies--culture and treat if positive and rapid strep with culture of negative results--are equally preferable for patients with Centor scores of 2; and rapid strep with culture of negative results is the best management strategy for patients with Centor scores 3 or 4. These results are sensitive to the priorities assigned to the decision criteria, especially avoiding over-use versus under-use of antibiotics, and the population prevalence of Group A streptococcal pharyngitis.

Conclusion: The optimal clinical management of adults with sore throat depends on both the clinical probability of a group A streptococcal infection and clinical judgments that incorporate individual patient and practice circumstances.

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