Original article 343
Acute sore throat in children at the emergency department: best medical practice? Inge Roggena, Gerlant van Berlaera, Frans Gordtsb, Denis Pierardc and Ives Hublouea Background Belgian antibiotic (AB) policy guidelines discourage the use of ABs in sore throat in otherwise healthy individuals; yet, 35% of all children with sore throat in our pediatric emergency department receive a prescription for ABs. Objective To identify factors influencing our physician’s prescription behavior. Patients and methods Using a retrospective study, we analyzed all medical records of children younger than 16 years of age diagnosed with sore throat (in 2009 and 2010). We included 1345 files. Results Children younger than 5 years of age received an AB prescription more easily (37.8 vs. 27.7%; P = 0.0007). Children of White origin received less frequent ABs compared with non-Whites (31.6 vs. 37.8%; P = 0.02). More ABs were prescribed during night shifts (38.7 vs. 31.8%; P = 0.008). Physicians with a Belgian degree prescribed less
Introduction Acute sore throat is the second most frequent complaint in the GP’s office in Europe and Northern America [1,2]. In Belgium, 3% of all GP consultations were for acute sore throat [1]. In children younger than 5 years of age, 95% of all cases of acute sore throat are caused by viruses, in children between 5 and 15 years of age, 70% is caused by viruses, and in children 15 years of age and older, viruses are the cause in 85–95% [1–4]. In all other cases, bacteria are the most common cause. The β hemolytic group A Streptococcus (GABHS) is the most common bacterial cause of acute sore throat [1,2,4–6]. However, when GABHS is found, it is not always the cause of the sore throat in 20–30%, when GABHS is found in a throat swab culture, this is because of asymptomatic carriership [1,7]. Other bacteria such as Streptococcus of group B or F are also found in throat swab culture, but to date, their role in acute sore throat is unclear [8]. Centor et al. [9] established four criteria to predict the probability of the presence of GABHS in a throat swab culture in adults. These criteria (fever > 38.5°C, swollen tender anterior cervical lymph nodes, tonsillar exudates, and absence of cough) were specifically developed for adults. Recently, several different altered Centor criteria for children became available including age (higher incidence of GABHS) [10] and runny nose (higher 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
frequently compared with those with a Dutch degree (23.4 vs. 46.4%; P < 0.0001). Conclusion We find several ‘practical’ factors to have an influence on the AB prescription rate. European Journal of Emergency Medicine 22:343–347 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:343–347 Keywords: acute sore throat, antibiotic policy, β hemolytic group A Streptococcus, pediatrics a Department of Emergency and Disaster Medicine, bDepartment of Otolaryngology - Head and Neck Surgery and cDepartment of Microbiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
Correspondence to Inge Roggen, MD, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Jette, Belgium Tel: +32 2 477 51 53; fax: +32 2 477 51 68; e-mail: [email protected] Received 13 February 2014 Accepted 27 May 2014
probability of a viral infection). The use of the Centor criteria to evaluate the presence of GABHS is under debate [11]. The Belgian Antibiotic Policy Coordination Committee (BAPCOC) guidelines on the use of antibiotics (ABs) in the treatment of acute sore throat in otherwise healthy individuals are based on the Cochrane review of Del Mar et al. [12]. They explain the limited added value of ABs in the treatment of acute sore throat even if GABHS is the etiological agent [13]. First, in the nontreated group, throat pain and fever disappeared within 72 h in, respectively, 40–85% of all patients, and there seems to be no difference between GABHS-caused and non-GABHScaused sore throat [12]. Second, suppurative complications such as acute otitis media, and retropharyngeal and peritonsillar abscesses appear more in the nontreated group, but the number needed to treat is too high to be advantageous and none of the complications is untreatable at the time of diagnosis. Finally, in Europe, the GABHS serotypes responsible for the nonsuppurative complications (rheumatic fever and post-Streptococcus glomerulonephritis) became extinct [12,14,15]. Yet, in Belgium, 50% of all patients with sore throat leave the GP’s office with a prescription for ABs [16]. DOI: 10.1097/MEJ.0000000000000175
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
344
European Journal of Emergency Medicine 2015, Vol 22 No 5
Fig. 1
33 152 total ED visits
Subset of children with sore throat (n=1586)
Statistical analysis was carried out using MedCalc version 12.3.0 (MedCalc Software bvba, Mariakerke, Belgium). All data are presented as mean ± SD or as median (range) when not normally distributed. D’Agostino– Pearson K2-test was used to assess normality of data. Spearman’s ρ-test was used to calculate rank correlation coefficients.
Results Exclusion criteria 1: underlying chronic respiratory, cardiac, hematological, or immunological disease (n=85)
Exclusion criteria 2: already received ABs before the PED visit (n=156)
Met all inclusion criteria (n=1345)
Flow chart showing the inclusion and exclusion criteria. AB, antibiotic; ED, emergency department; PED, pediatric emergency department.
Patients and methods In this retrospective observational record review study, we analyzed all medical records of children younger than 16 years of age who were admitted to our emergency department (ED) between 1 January 2009 and 31 December 2010. The study was approved by the local ethical committee of the UZ Brussel University Hospital. All our records are digitalized and all diagnoses in our records are registered according to the International Statistical Classification of Diseases and Related Health Problems (ICD-9) codes. All files with the following ICD-9 codes scarlatina (034), infectious mononucleosis (075), nasopharyngitis (460), pharyngitis (462), tonsillitis (463), and sore throat (784.1) were included for analysis. Children with underlying chronic diseases and children who already received ABs before the ED consult were excluded. Forty-six children were excluded after it became clear that pneumonia, rather than sore throat, was the main cause for their febrile illness. Only records with complete information on history of disease (duration and height of fever and presence or absence of runny nose, cough, sore throat, and loss of appetite) and full clinical examination (temperature, throat examination, and cervical lymph node evaluation) were selected. Other possible factors that might influence prescription behavior, which were also included were, origin and mother tongue of the patient, country of origin of the degree of the physician, and time and day of the ED visit.
In the study period, 33 152 children visited our ED; 1345 (723 boys, 622 girls) fulfilled our criteria (Fig. 1). The median age (range) of the children was 3.1 years (3.5 months–15.6 years). Of all patients, 262 (19.5%) had Dutch as their mother tongue and 1083 (80.5%) were French speaking; 585 (43.5%) were of White origin, 557 (41.4%) of Maghreb origin, 81 (6.0%) originated from the Middle East, and 122 (9.1%) were from Central and Southern Africa; 662 (49.1%) were seen by a physician with a Belgian degree and 683 (50.8%) were seen by a physician with a Dutch degree; and 699 (52.0%) were seen during the day shift (8 a.m.–6 p.m.) and 646 (48.0%) during the night shift. There was no difference in sex or age distribution between the different origins, either in origin or mother tongue of the patients, between those seen by Belgian and Dutch doctors, or in their time of presentation at the ED. Of all patients, otherwise healthy, 35.1% received a prescription for AB. There was no correlation between fever (history, duration, or fever at the time of the consult), absence of coughing, runny nose, or tender swollen cervical anterior lymph nodes, and the rate of AB prescriptions. The only independent clinical parameter that correlated with the prescription rate was the presence of tonsillar exudate (r = 0.39; P < 0.0001); yet, in our population, the incidence of tonsillar exudate was lower in children with a positive throat swab culture for GABHS (48.3 vs. 58.3%; P = 0.07). When we combined clinical parameters in the Centor criteria, we observed an increase in the prescription rate when more criteria were present. When none of the Centor criteria were present (n = 40), 10.0% of the patients received an AB prescription, when one criterion was present (n = 283) the prescription rate increased to 25.1%, for two criteria (n = 528), this was 30.3%, for three criteria (n = 384), this was 45.3%, and when all four criteria were present (n = 110), 57.3% of patients were prescribed ABs, P less than 0.05 for all differences; only the difference in ABs prescribed between one and two criteria was not significant. Yet, we did not find a significant difference for the presence of GABHS in throat swab cultures for the different groups: 0–4 Centor criteria, showed 50.0, 30.6, 25.9, 27.3, and 22.7%, respectively. Only when the final diagnosis was scarlatina was the prescription rate higher (86%); for all other diagnoses, the prescription rate ranged between 31 and 38% (Table 1).
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Acute sore throat in children at the ED Roggen et al. 345
Table 1
Prescription rate of antibiotics according to diagnosis
Diagnosis (ICD-9)
N
Nasopharyngitis (460) Pharyngitis (462) Tonsillitis (463) Scarlatina (034) Mononucleosis (075) Sore throat (784.1)
Received ABs [N (%)]
325 888 711 86 76 433
112 308 271 74 26 135
(34) (34) (38) (86) (34) (31)
Some files included more than one diagnosis. AB, antibiotic; ICD, International Statistical Classification of Diseases and Related Health Problems.
When examining other possible factors that could have an influence on prescription behavior, we found the following factors: doctors with a Dutch degree prescribed double the amount of ABs (46.4 vs. 23.4%; P < 0.0001) and, they prescribed more often when the patient spoke French (47.8 vs. 40.6%; P = 0.1). Patients of non-White origin received ABs more frequently (37.8 vs. 31.6%; P = 0.02). More ABs were prescribed during the night shift (38.7 vs. 31.8%; P = 0.008), although children were not perceived as sicker at night (Table 2). On weekends and on bank holidays (36.7 vs. 33.9%; P = 0.3), prescription rates were slightly increased. Of all children, 423 (31.4%) had a throat swab taken: the incidence of GABHS is almost double as high in children 5 to 16 years of age (22.5 vs. 41.4%; P = 0.0002); yet, children younger than 5 years of age received an AB prescription more easily (37.8 vs. 27.7%; P = 0.0007). When a throat swab for GABHS culture was performed, irrespective of the result, ABs were more often prescribed (44.9 vs. 30.6%; P < 0.0001); this was also the case in children who had a chest radiography done (46.6 vs. 34.0%; P = 0.007) or blood analysis done (41.6 vs. 34.2%; P = 0.06), irrespective of the result. (Note: All children with pneumonia on chest radiograph were excluded.) All significant results are shown in Fig. 2.
Discussion Belgian guidelines on the uselessness of ABs in (otherwise healthy) children with sore throat are very clear, and yet, we found that one in three children still received a prescription for ABs in our ED. At least it is lower than the prescription rate at the GP’s office in Belgium, where one in two patients receive a prescription for AB. In terms of age, physicians seem reluctant to send a young child home without ABs, whereas it is known that Table 2 Comparison between reported fever and intake in children admitted during the day or the night
Shift Day Night P-value
Total number of patients
No fever reported [n (%)]
Fever reported [n (%)]
No intake [n (%)]
Normal intake [n (%)]
699 646
150 (21) 125 (19) 0.5
508 (72) 493 (76) 0.1
432 (62) 395 (61) 0.9
267 (38) 251 (39) 0.9
the incidence of GABHS is five-fold lower in these children [1–4]. It is also known that children younger than 5 years of age, compared with older children, tend to be much more prone to viral upper respiratory tract infections in general [17,18]. In contrast, children who had a throat swab for GABHS culture taken received an AB prescription more often than those who had not. It may be surmised that when a throat swab is taken, those with a positive culture would be contacted and sent to their GP’s office to collect an AB prescription, rather than being started with ABs without waiting for the result. (Note: In our ED, a quality assurance nurse tracks all results and contacts patients or their parents when aberrant results emerge.) When we combined clinical parameters in the Centor criteria, we observed an increase in the prescription rate; this can be explained by the fact that the more the criteria present, the sicker the child may appear to both the parents and the physician. The most interesting result of this study is probably the magnitude of the role played by practical factors. Although the same physicians work in rotating shifts, the same physicians prescribe ABs more easily during their night shift compared with the day shift. Although the Netherlands is known for its strict AB policy [19] and strict adherence to this policy [20], residents with a Dutch degree, working in a Belgian ED, prescribe double the amount of ABs compared with residents with a Belgian degree. This can partially be explained by the language barrier as there is a difference (albeit not significant) in prescription behavior when comparing French-speaking and Dutch-speaking patients (a difference that is absent when considering physicians with a Belgian degree). However, when we studied only Dutchspeaking patients, we could still observe that a resident with a Dutch degree will prescribe two-fold more frequently than their Belgian colleagues; thus, other factors – which have not been identified to date must definitely play a role. Limitations
The major limitation of this study is its retrospective nature. We had to rely on the information written down in patient files, which might be incomplete. Thus, as several physicians tend to write down a list of differential diagnoses rather than one clear-cut diagnosis, our conclusions on prescription behavior are limited in respect to the different throat infections (e.g. GABHS might justify ABs, but in mononucleosis ABs are contraindicated). Conclusion
Even though Belgian AB policy guidelines clearly discourage the use of ABs in sore throat, in otherwise healthy individuals, 35% of all children with sore throat in our pediatric ED receive a prescription for ABs. Rather
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346 European Journal of Emergency Medicine 2015, Vol 22 No 5
AB prescription rate
Fig. 2
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.0
0.0
AB prescription rate
Dutch degree
Belgian degree
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.0
Other origin
Age < 5
Age > 5
No chest radiography
Chest radiography
0.0 Day shift
AB prescription rate
White origin
Night shift
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.0
0.0 No throat swab taken
Throat swab taken
Factors influencing prescription behavior: doctors’ degree (46.4 vs. 23.4%; P < 0.0001); patients’ region of origin (31.6 vs. 37.8%; P = 0.02); time of admission at ED (31.8 vs. 38.7%; P = 0.008); the child’s age (37.8 vs. 27.7%; P = 0.0007); whether throat swab was performed (30.6 vs. 44.9%; P < 0.0001); and whether chest radiography was performed (34.0 vs. 46.6%; P = 0.007). AB, antibiotic; ED, emergency department.
than clinical arguments, circumstantial factors such as age of the patient, time of presentation, and background of
the physician seem to play an important role in the prescription behavior at our pediatric ED.
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Acute sore throat in children at the ED Roggen et al. 347
Acknowledgements
10
The authors thank Ms Annemieke Verholle, who keeps the databases with patient information and ICD-9 codes up-to-date.
11 12
Conflicts of interest
13
There are no conflicts of interest.
References
14
1 De Meyere M, Matthys J. Acute sore throat: WVVH-recommendations for good medical practice. 1999. 2 Worrall G. Acute sore throat. There’s a lot of it about: acute respiratory infections in primary care. Oxford: Radcliffe Publishing Ltd; 2006. pp. 24–36. 3 Linder J, Bates D, Lee G, Finkelstein J. Antibiotic treatment of children with sore throat. JAMA 2005; 294:2315–2322. 4 Ruppert S. Differential diagnosis of common causes of pediatric pharyngitis. Nurse Pract 1996; 21:38–42, 44, 47–48. 5 Schroeder B. Diagnosis and management of group A streptococcal pharyngitis. Am Fam Physician 2003; 67:880 883–884. 6 Vincent M, Celestin N, Hussain A. Pharyngitis. Am Fam Physician 2004; 69:1465–1470. 7 Bisno A, Gerber M, Gwaltney JJ, Kaplan E, Schwartz R. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis 2002; 35:113–125. 8 Dagnelie C. Bacterial flora in patients presenting with sore throat in dutch general practice. Fam Pract 1993; 10:371–377. 9 Centor R, Witherspoon J, Dalton H, Brody C, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981; 1:239–246.
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McIsaac W, Kellner J, Aufricht P, Vanjaka A, Low D. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004; 291:1587–1595. Regoli M, Chiappini E, Bonsignori F, Galli L, de Martino M. Update on the management of acute pharyngitis in children. Ital J Pediatr 2011; 37:10. Del Mar C, Glasziou P, Spinks A. Antibiotics for sore throat. Cochrane Database Syst Rev 2006; 18:CD000023. BAPCOC. Belgische gids voor anti-infectieuze behandeling in de ambulante praktijk - editie 2008. Available at: http://www.health.belgium.be/ filestore/15616531/832250_BW_NL_01_84_IC_15616531_nl.pdf. Accessed 4 October 2010. Demonty J. Is prophylaxis for acute rheumatic fever part of current practice? Rev Med Liege 2002; 57:340–342. Weinstein L, Le Frock J. Does antimicrobial therapy of streptococcal pharyngitis or pyoderma alter the risk of. J Infect Dis 1971; 124:229–231. Van der Heyden J, Van Casteren V, Bastiaens H, Jonckheer P. Antibiotics in acute sore throat: results of a registration in the Belgian general practitioner’s office. Vlaams Infectieziektebulletin 2001; 37:4–8. Hak E, Rovers M, Kuyvenhoven M, Schellevis F, Verheij T. Incidence of GPdiagnosed respiratory tract infections according to age, gender and high-risk co-morbidity: the Second Dutch National Survey of General Practice. Fam Pract 2006; 23:291–294. Van den Bruel A, Bartholomeeusen S, Aertgeerts B, Truyers C, Buntinx F. Serious infections in children: an incidence study in family practice. BMC Fam Pract 2006; 7:23. Van Kasteren M, Wijnands W, Stobberingh E, Janknegt R, Verbrugh H, van der Meer J. Optimizing antibiotics use policy in the Netherlands. I. The Netherlands Antibiotics Policy Foundation (SWAB). Ned Tijdschr Geneeskd 1998; 142:949–951. Ferech M, Coenen S, Malhotra-Kumar S, Dvorakova K, Hendrickx E, Suetens C, Goossens H. ESACProject Group. European surveillance of antimicrobial consumption (ESAC): outpatient antibiotic use in Europe. J Antimicrob Chemother 2006; 58:401–407.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Acute sore throat in children at the emergency department: best medical practice? Inge Roggena, Gerlant van Berlaera, Frans Gordtsb, Denis Pierardc and Ives Hublouea Background Belgian antibiotic (AB) policy guidelines discourage the use of ABs in sore throat in otherwise healthy individuals; yet, 35% of all children with sore throat in our pediatric emergency department receive a prescription for ABs. Objective To identify factors influencing our physician’s prescription behavior. Patients and methods Using a retrospective study, we analyzed all medical records of children younger than 16 years of age diagnosed with sore throat (in 2009 and 2010). We included 1345 files. Results Children younger than 5 years of age received an AB prescription more easily (37.8 vs. 27.7%; P = 0.0007). Children of White origin received less frequent ABs compared with non-Whites (31.6 vs. 37.8%; P = 0.02). More ABs were prescribed during night shifts (38.7 vs. 31.8%; P = 0.008). Physicians with a Belgian degree prescribed less
Introduction Acute sore throat is the second most frequent complaint in the GP’s office in Europe and Northern America [1,2]. In Belgium, 3% of all GP consultations were for acute sore throat [1]. In children younger than 5 years of age, 95% of all cases of acute sore throat are caused by viruses, in children between 5 and 15 years of age, 70% is caused by viruses, and in children 15 years of age and older, viruses are the cause in 85–95% [1–4]. In all other cases, bacteria are the most common cause. The β hemolytic group A Streptococcus (GABHS) is the most common bacterial cause of acute sore throat [1,2,4–6]. However, when GABHS is found, it is not always the cause of the sore throat in 20–30%, when GABHS is found in a throat swab culture, this is because of asymptomatic carriership [1,7]. Other bacteria such as Streptococcus of group B or F are also found in throat swab culture, but to date, their role in acute sore throat is unclear [8]. Centor et al. [9] established four criteria to predict the probability of the presence of GABHS in a throat swab culture in adults. These criteria (fever > 38.5°C, swollen tender anterior cervical lymph nodes, tonsillar exudates, and absence of cough) were specifically developed for adults. Recently, several different altered Centor criteria for children became available including age (higher incidence of GABHS) [10] and runny nose (higher 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
frequently compared with those with a Dutch degree (23.4 vs. 46.4%; P < 0.0001). Conclusion We find several ‘practical’ factors to have an influence on the AB prescription rate. European Journal of Emergency Medicine 22:343–347 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:343–347 Keywords: acute sore throat, antibiotic policy, β hemolytic group A Streptococcus, pediatrics a Department of Emergency and Disaster Medicine, bDepartment of Otolaryngology - Head and Neck Surgery and cDepartment of Microbiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
Correspondence to Inge Roggen, MD, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Jette, Belgium Tel: +32 2 477 51 53; fax: +32 2 477 51 68; e-mail: [email protected] Received 13 February 2014 Accepted 27 May 2014
probability of a viral infection). The use of the Centor criteria to evaluate the presence of GABHS is under debate [11]. The Belgian Antibiotic Policy Coordination Committee (BAPCOC) guidelines on the use of antibiotics (ABs) in the treatment of acute sore throat in otherwise healthy individuals are based on the Cochrane review of Del Mar et al. [12]. They explain the limited added value of ABs in the treatment of acute sore throat even if GABHS is the etiological agent [13]. First, in the nontreated group, throat pain and fever disappeared within 72 h in, respectively, 40–85% of all patients, and there seems to be no difference between GABHS-caused and non-GABHScaused sore throat [12]. Second, suppurative complications such as acute otitis media, and retropharyngeal and peritonsillar abscesses appear more in the nontreated group, but the number needed to treat is too high to be advantageous and none of the complications is untreatable at the time of diagnosis. Finally, in Europe, the GABHS serotypes responsible for the nonsuppurative complications (rheumatic fever and post-Streptococcus glomerulonephritis) became extinct [12,14,15]. Yet, in Belgium, 50% of all patients with sore throat leave the GP’s office with a prescription for ABs [16]. DOI: 10.1097/MEJ.0000000000000175
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
344
European Journal of Emergency Medicine 2015, Vol 22 No 5
Fig. 1
33 152 total ED visits
Subset of children with sore throat (n=1586)
Statistical analysis was carried out using MedCalc version 12.3.0 (MedCalc Software bvba, Mariakerke, Belgium). All data are presented as mean ± SD or as median (range) when not normally distributed. D’Agostino– Pearson K2-test was used to assess normality of data. Spearman’s ρ-test was used to calculate rank correlation coefficients.
Results Exclusion criteria 1: underlying chronic respiratory, cardiac, hematological, or immunological disease (n=85)
Exclusion criteria 2: already received ABs before the PED visit (n=156)
Met all inclusion criteria (n=1345)
Flow chart showing the inclusion and exclusion criteria. AB, antibiotic; ED, emergency department; PED, pediatric emergency department.
Patients and methods In this retrospective observational record review study, we analyzed all medical records of children younger than 16 years of age who were admitted to our emergency department (ED) between 1 January 2009 and 31 December 2010. The study was approved by the local ethical committee of the UZ Brussel University Hospital. All our records are digitalized and all diagnoses in our records are registered according to the International Statistical Classification of Diseases and Related Health Problems (ICD-9) codes. All files with the following ICD-9 codes scarlatina (034), infectious mononucleosis (075), nasopharyngitis (460), pharyngitis (462), tonsillitis (463), and sore throat (784.1) were included for analysis. Children with underlying chronic diseases and children who already received ABs before the ED consult were excluded. Forty-six children were excluded after it became clear that pneumonia, rather than sore throat, was the main cause for their febrile illness. Only records with complete information on history of disease (duration and height of fever and presence or absence of runny nose, cough, sore throat, and loss of appetite) and full clinical examination (temperature, throat examination, and cervical lymph node evaluation) were selected. Other possible factors that might influence prescription behavior, which were also included were, origin and mother tongue of the patient, country of origin of the degree of the physician, and time and day of the ED visit.
In the study period, 33 152 children visited our ED; 1345 (723 boys, 622 girls) fulfilled our criteria (Fig. 1). The median age (range) of the children was 3.1 years (3.5 months–15.6 years). Of all patients, 262 (19.5%) had Dutch as their mother tongue and 1083 (80.5%) were French speaking; 585 (43.5%) were of White origin, 557 (41.4%) of Maghreb origin, 81 (6.0%) originated from the Middle East, and 122 (9.1%) were from Central and Southern Africa; 662 (49.1%) were seen by a physician with a Belgian degree and 683 (50.8%) were seen by a physician with a Dutch degree; and 699 (52.0%) were seen during the day shift (8 a.m.–6 p.m.) and 646 (48.0%) during the night shift. There was no difference in sex or age distribution between the different origins, either in origin or mother tongue of the patients, between those seen by Belgian and Dutch doctors, or in their time of presentation at the ED. Of all patients, otherwise healthy, 35.1% received a prescription for AB. There was no correlation between fever (history, duration, or fever at the time of the consult), absence of coughing, runny nose, or tender swollen cervical anterior lymph nodes, and the rate of AB prescriptions. The only independent clinical parameter that correlated with the prescription rate was the presence of tonsillar exudate (r = 0.39; P < 0.0001); yet, in our population, the incidence of tonsillar exudate was lower in children with a positive throat swab culture for GABHS (48.3 vs. 58.3%; P = 0.07). When we combined clinical parameters in the Centor criteria, we observed an increase in the prescription rate when more criteria were present. When none of the Centor criteria were present (n = 40), 10.0% of the patients received an AB prescription, when one criterion was present (n = 283) the prescription rate increased to 25.1%, for two criteria (n = 528), this was 30.3%, for three criteria (n = 384), this was 45.3%, and when all four criteria were present (n = 110), 57.3% of patients were prescribed ABs, P less than 0.05 for all differences; only the difference in ABs prescribed between one and two criteria was not significant. Yet, we did not find a significant difference for the presence of GABHS in throat swab cultures for the different groups: 0–4 Centor criteria, showed 50.0, 30.6, 25.9, 27.3, and 22.7%, respectively. Only when the final diagnosis was scarlatina was the prescription rate higher (86%); for all other diagnoses, the prescription rate ranged between 31 and 38% (Table 1).
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Acute sore throat in children at the ED Roggen et al. 345
Table 1
Prescription rate of antibiotics according to diagnosis
Diagnosis (ICD-9)
N
Nasopharyngitis (460) Pharyngitis (462) Tonsillitis (463) Scarlatina (034) Mononucleosis (075) Sore throat (784.1)
Received ABs [N (%)]
325 888 711 86 76 433
112 308 271 74 26 135
(34) (34) (38) (86) (34) (31)
Some files included more than one diagnosis. AB, antibiotic; ICD, International Statistical Classification of Diseases and Related Health Problems.
When examining other possible factors that could have an influence on prescription behavior, we found the following factors: doctors with a Dutch degree prescribed double the amount of ABs (46.4 vs. 23.4%; P < 0.0001) and, they prescribed more often when the patient spoke French (47.8 vs. 40.6%; P = 0.1). Patients of non-White origin received ABs more frequently (37.8 vs. 31.6%; P = 0.02). More ABs were prescribed during the night shift (38.7 vs. 31.8%; P = 0.008), although children were not perceived as sicker at night (Table 2). On weekends and on bank holidays (36.7 vs. 33.9%; P = 0.3), prescription rates were slightly increased. Of all children, 423 (31.4%) had a throat swab taken: the incidence of GABHS is almost double as high in children 5 to 16 years of age (22.5 vs. 41.4%; P = 0.0002); yet, children younger than 5 years of age received an AB prescription more easily (37.8 vs. 27.7%; P = 0.0007). When a throat swab for GABHS culture was performed, irrespective of the result, ABs were more often prescribed (44.9 vs. 30.6%; P < 0.0001); this was also the case in children who had a chest radiography done (46.6 vs. 34.0%; P = 0.007) or blood analysis done (41.6 vs. 34.2%; P = 0.06), irrespective of the result. (Note: All children with pneumonia on chest radiograph were excluded.) All significant results are shown in Fig. 2.
Discussion Belgian guidelines on the uselessness of ABs in (otherwise healthy) children with sore throat are very clear, and yet, we found that one in three children still received a prescription for ABs in our ED. At least it is lower than the prescription rate at the GP’s office in Belgium, where one in two patients receive a prescription for AB. In terms of age, physicians seem reluctant to send a young child home without ABs, whereas it is known that Table 2 Comparison between reported fever and intake in children admitted during the day or the night
Shift Day Night P-value
Total number of patients
No fever reported [n (%)]
Fever reported [n (%)]
No intake [n (%)]
Normal intake [n (%)]
699 646
150 (21) 125 (19) 0.5
508 (72) 493 (76) 0.1
432 (62) 395 (61) 0.9
267 (38) 251 (39) 0.9
the incidence of GABHS is five-fold lower in these children [1–4]. It is also known that children younger than 5 years of age, compared with older children, tend to be much more prone to viral upper respiratory tract infections in general [17,18]. In contrast, children who had a throat swab for GABHS culture taken received an AB prescription more often than those who had not. It may be surmised that when a throat swab is taken, those with a positive culture would be contacted and sent to their GP’s office to collect an AB prescription, rather than being started with ABs without waiting for the result. (Note: In our ED, a quality assurance nurse tracks all results and contacts patients or their parents when aberrant results emerge.) When we combined clinical parameters in the Centor criteria, we observed an increase in the prescription rate; this can be explained by the fact that the more the criteria present, the sicker the child may appear to both the parents and the physician. The most interesting result of this study is probably the magnitude of the role played by practical factors. Although the same physicians work in rotating shifts, the same physicians prescribe ABs more easily during their night shift compared with the day shift. Although the Netherlands is known for its strict AB policy [19] and strict adherence to this policy [20], residents with a Dutch degree, working in a Belgian ED, prescribe double the amount of ABs compared with residents with a Belgian degree. This can partially be explained by the language barrier as there is a difference (albeit not significant) in prescription behavior when comparing French-speaking and Dutch-speaking patients (a difference that is absent when considering physicians with a Belgian degree). However, when we studied only Dutchspeaking patients, we could still observe that a resident with a Dutch degree will prescribe two-fold more frequently than their Belgian colleagues; thus, other factors – which have not been identified to date must definitely play a role. Limitations
The major limitation of this study is its retrospective nature. We had to rely on the information written down in patient files, which might be incomplete. Thus, as several physicians tend to write down a list of differential diagnoses rather than one clear-cut diagnosis, our conclusions on prescription behavior are limited in respect to the different throat infections (e.g. GABHS might justify ABs, but in mononucleosis ABs are contraindicated). Conclusion
Even though Belgian AB policy guidelines clearly discourage the use of ABs in sore throat, in otherwise healthy individuals, 35% of all children with sore throat in our pediatric ED receive a prescription for ABs. Rather
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346 European Journal of Emergency Medicine 2015, Vol 22 No 5
AB prescription rate
Fig. 2
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.0
0.0
AB prescription rate
Dutch degree
Belgian degree
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.0
Other origin
Age < 5
Age > 5
No chest radiography
Chest radiography
0.0 Day shift
AB prescription rate
White origin
Night shift
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.0
0.0 No throat swab taken
Throat swab taken
Factors influencing prescription behavior: doctors’ degree (46.4 vs. 23.4%; P < 0.0001); patients’ region of origin (31.6 vs. 37.8%; P = 0.02); time of admission at ED (31.8 vs. 38.7%; P = 0.008); the child’s age (37.8 vs. 27.7%; P = 0.0007); whether throat swab was performed (30.6 vs. 44.9%; P < 0.0001); and whether chest radiography was performed (34.0 vs. 46.6%; P = 0.007). AB, antibiotic; ED, emergency department.
than clinical arguments, circumstantial factors such as age of the patient, time of presentation, and background of
the physician seem to play an important role in the prescription behavior at our pediatric ED.
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Acute sore throat in children at the ED Roggen et al. 347
Acknowledgements
10
The authors thank Ms Annemieke Verholle, who keeps the databases with patient information and ICD-9 codes up-to-date.
11 12
Conflicts of interest
13
There are no conflicts of interest.
References
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