Background<\/strong><\/p>\nAcute tonsillopharyngitis is a common reason for consult in the primary care setting. Although most cases are viral in etiology, more than half of patients with acute tonsillopharyngitis still receive antibiotic therapy for group A beta-hemolytic streptococcal infection.\u00a0 Streptococcal throat infection may lead uncommonly to suppurative complications like peritonsillar abscess and non-suppurative complications like acute rheumatic fever. It is with this consideration that streptococcal throat infection must be distinguished from viral infections. Clinical practice guidelines have focused their efforts on how it can be accurately diagnosed to prevent complications while reducing unnecessary antibiotic prescribing.<\/p>\n
Objective<\/strong><\/p>\nThis clinical pathway was developed to serve as guidance for family and community medicine practitioners in making clinical decisions regarding the diagnosis and management of acute tonsillophrayngitis.<\/p>\n
Methods<\/strong><\/p>\nAfter defining the scope of the pathway, the Â鶹ֱ²¥ Clinical Pathways Group first identified the key issues in managing patient with acute tonsillopharyngitis. These key issues were then translated to review question. The group then reviewed the published medical literature to identify, summarize, and operationalize the evidence in clinical publication. Databases were first searched for existing clinical practice guidelines from reputable medical organizations. Further search for evidence was also conducted using the terms \u201ctonsillopharyngitis\u201d or \u201ctonsillitis\u201d, \u201cdiagnosis\u201d and \u201ctreatment\u201d. Evidence was then summarized and its quality assessed using the modified GRADE approach. From the evidence-based summaries, the CPDG then developed general guideline and pathway recommendations which are stated as time-bound tasks of patient-care processes in the management of acute tonsillopharyngitis in family and community practice. The recommendations were then presented to a panel of family and community practitioners in both urban and rural settings, for a consensus agreement on the applicability of the recommendations to family and community practice. Lastly, the final clinical pathway was written and developed to include the recommendations, the clinical pathway tables, and an algorithm.\u00a0 The clinical pathway can be used as a checklist or standards of care. The algorithm can be used to explain the process of care to the patient<\/p>\n
Recommendations<\/strong><\/p>\nThis clinical pathway contains updates on recommendations in the 2010 clinical practice guidelines on acute tonsillophrayngitis. Recommendations on the utilization of clinical scoring and rapid antigen tests as basis for deciding on need for antibiotic therapy comprise the major changes from the previously published guidelines. Penicillin remains as the first-line antibiotic therapy for streptococcal throat infection.<\/p>\n
SUMMARY OF RECOMMENDATIONS<\/p>\n
\n\n\nHistory and Physical Exam<\/em><\/td>\n<\/tr>\n\n| FIRST VISIT<\/td>\n<\/tr>\n | \n| Elicit history of throat pain and its intensity, fever and painful lymph nodes on the neck and duration of symptoms. (AII)<\/td>\n<\/tr>\n | \n| Elicit history of recurrent tonsillopharyngitis, peritonsillar abscess and drug allergies (AII)<\/td>\n<\/tr>\n | \n| Evaluate socioeconomic status (BII)<\/td>\n<\/tr>\n | \n| Examine for fever, tonsillar swelling, exudates, and cervical lymphadenitis. (AII)<\/td>\n<\/tr>\n | \n| Examine for signs of dehydration (BIII)<\/td>\n<\/tr>\n | \n| Obtain the Centor or FeverPAIN score to determine probability of streptococcal infection (AII)<\/td>\n<\/tr>\n | \n| SECOND VISIT<\/td>\n<\/tr>\n | \n| Re-evaluate the presence of throat pain and its intensity, fever, tonsillopharyngeal congestion, and tonsillar exudates (AII)<\/td>\n<\/tr>\n | \n| Assess adherence to treatment (AII) and explore reasons for non-adherence (AIII)<\/td>\n<\/tr>\n | \n| Ask for presence of any adverse drug event (AIII)<\/td>\n<\/tr>\n | \n| Examine for signs of suppurative complications if with no improvement in symptoms (AII)<\/td>\n<\/tr>\n | \nDiagnostic Exam<\/em><\/td>\n<\/tr>\n\n| Offer rapid antigen test for Streptococcal infection to patients 3 years of age and older with Centor score of \u22653, if available (CII)<\/td>\n<\/tr>\n | \n| Offer throat swab and culture if initial antibiotic treatment fails (AII)<\/td>\n<\/tr>\n | \nPharmacologic Intervention<\/em><\/td>\n<\/tr>\n\n| FIRST VISIT<\/td>\n<\/tr>\n | \n| Offer symptomatic treatment with paracetamol or NSAID in lozenge or oral form. (AI)<\/td>\n<\/tr>\n | \n| In adult patients with more severe presentations e.g Centor score \u22653 , consider offering a single low-dose corticosteroid (AI)<\/td>\n<\/tr>\n | \n| Antibiotics should only be offered if the rapid antigen test is positive or if Centor score is \u22653 or FeverPAIN score is \u22654. Penicillin or Amoxicillin is given as first-line antibiotic treatment. Cephalosporins and macrolides are given in case of allergies to penicillin (AI)<\/td>\n<\/tr>\n | \n| SECOND VISIT<\/td>\n<\/tr>\n | \n| If with symptom improvement within 1 week, complete the prescribed antibiotic regimen (AI)<\/td>\n<\/tr>\n | \n| If with no improvement or if with worsening of symptoms despite adherence or if with adverse reactions to the previously prescribed antibiotics, offer change in antibiotics (AII)<\/td>\n<\/tr>\n | \n| If no improvement or worsening of symptoms because of poor adherence, continue the first antibiotic prescribed and complete the prescribed regimen (AIII)<\/td>\n<\/tr>\n | \nNon-pharmacologic Intervention<\/em><\/td>\n<\/tr>\n\n| Advise increase oral fluid intake for adequate hydration and soft diet (AIII) for patients with odynophagia and consider home remedies such as salt-water gargles (AII)<\/td>\n<\/tr>\n | \n| Consider offering chlorhexidine plus benzydamine\u00a0 combination throat spray (AI), if available or chlorhexidine or benzydamine oral spray for symptomatic relief\u00a0 (AII)<\/td>\n<\/tr>\n | \n| Educate regarding possible etiologies of acute pharyngitis, transmission, and complications of Streptococcal pharyngitis (AIII)<\/td>\n<\/tr>\n | \n| Educate regarding the dose, frequency, possible adverse effects of medications and the importance of completing the prescribed antibiotic regimen (AII)<\/td>\n<\/tr>\n | \n| To reduce transmission, educate regarding cough and sneeze etiquette and hand hygiene and advise to stay home until afebrile and\/or completion of \u2265 24 hours of appropriate antibiotic therapy (AIII)<\/td>\n<\/tr>\n | \n| Educate the family regarding possible etiologies of acute pharyngitis, transmission, treatment and complications of Streptococcal pharyngitis (AIII)<\/td>\n<\/tr>\n | \n| Explore and educate on exposure to possible irritants in the community and the workplace\u00a0 (AIII)<\/td>\n<\/tr>\n | \n| SECOND VISIT<\/td>\n<\/tr>\n | \n| If symptoms are still present, reinforce advice on use of supportive treatment and home remedies for symptomatic relief (AII)<\/td>\n<\/tr>\n | \n| Reinforce health education regarding possible complications and treatment of Streptococcal pharyngitis (AIII)<\/td>\n<\/tr>\n | \n| Reinforce education on hand hygiene and cough and sneeze etiquette to reduce transmission (AIII)<\/td>\n<\/tr>\n | \n| Reinforce education on the proper dosage and intake of antibiotics (AII) and provide counseling on adherence to medications (AII)<\/td>\n<\/tr>\n | \n| Reinforce health education regarding transmission, treatment and\u00a0 possible complications of Streptococcal pharyngitis (AIII)<\/td>\n<\/tr>\n | \n| Reinforce advice on avoidance of exposure to possible irritants in the community and the workplace (AIII)<\/td>\n<\/tr>\n | \nPatient Outcomes<\/em><\/td>\n<\/tr>\n\n| Receives information about acute tonsillopharyngitis \u2013 possible etiologies and complications and agrees with pharmacologic and non-pharmacologic treatment plan (AIII)<\/td>\n<\/tr>\n | \n| Aware of the dose, frequency, indications and side effects of the medications given (AII)<\/td>\n<\/tr>\n | \n| Aware of the importance of compliance with antibiotic treatment and follow-up (AII)<\/td>\n<\/tr>\n | \n| Advise patient to follow-up after 7 days to assess for improvement or at any time if with worsening of symptoms (AII)<\/td>\n<\/tr>\n | \n| Symptom improvement or resolution (AII)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n Implementation<\/strong><\/p>\nImplementation of the clinical pathway will be at the practice and the organizational levels. The pathway may be used as a checklist to guide family medicine specialists or general practitioners in individual clinic and community medicine practice. It may also be used as reference for exams by the training programs and the specialty board. In the commitment to achieve the goal of improving the effectiveness, efficiency and quality of patient care in family and community practice, the clinical pathway may also be implemented through quality improvement activities in the form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Organizational outcomes can be activities of the Â鶹ֱ²¥ devoted to the promotion, development, dissemination and implementation of clinical pathways.<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"featured_media":0,"template":"","meta":{"_acf_changed":false,"footnotes":""},"categories":[14,18],"tags":[16],"class_list":["post-3196","abstract","type-abstract","status-publish","hentry","category-abstract","category-abstract_2021_vol59_issue2","tag-abstract"],"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/thepafp.org\/journal\/wp-json\/wp\/v2\/abstract\/3196","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/thepafp.org\/journal\/wp-json\/wp\/v2\/abstract"}],"about":[{"href":"https:\/\/thepafp.org\/journal\/wp-json\/wp\/v2\/types\/abstract"}],"version-history":[{"count":7,"href":"https:\/\/thepafp.org\/journal\/wp-json\/wp\/v2\/abstract\/3196\/revisions"}],"predecessor-version":[{"id":3347,"href":"https:\/\/thepafp.org\/journal\/wp-json\/wp\/v2\/abstract\/3196\/revisions\/3347"}],"wp:attachment":[{"href":"https:\/\/thepafp.org\/journal\/wp-json\/wp\/v2\/media?parent=3196"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/thepafp.org\/journal\/wp-json\/wp\/v2\/categories?post=3196"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/thepafp.org\/journal\/wp-json\/wp\/v2\/tags?post=3196"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}} | | | | | |