Dippel D W, Touw-Otten F, Habbema J D
Department of Public Health and Social Medicine, Erasmus University, Rotterdam, The Netherlands.
J Fam Pract. 1992 Feb;34(2):149-59.
Although the incidence of acute rheumatic fever has declined in the last decades, a few outbreaks have recently been reported. A rapid latex agglutination test for group A streptococci seems reasonably accurate, and early treatment of acute pharyngitis seems to influence the pharyngitis itself. These factors have promoted uncertainty concerning the current best management of patients with sore throat.
Clinical decision analysis is used to compare the risks and benefits of symptomatic treatment, and oral and intramuscular penicillin as therapeutic options, and the throat culture and the rapid latex agglutination test as diagnostic strategies. Best estimates of the risk of streptococcal pharyngitis, its complications, the carrier rate, the accuracy of diagnostic tests, the efficacy of antibiotic treatment, allergic reactions, medication compliance, and health outcomes are combined into a management advisory. All results are subjected to a sensitivity analysis in order to check their strength against plausible changes in assumptions. Quality adjusted life days (QALD) lost are used as an outcome measure.
The agglutination test combined with oral penicillin yielded the lowest expected loss (.50) of QALD for a typical child with a risk of harboring streptococci of .60. The other strategies, however, yielded losses that were only several hundredths of QALD higher.
For children with at least a 40% chance of harboring streptococci and a duration of complaints of less than 2 days before starting treatment, diagnostic testing and prescription of oral penicillin appear to be the best choice of initial management. The rapid latex agglutination test is more effective than the throat culture, because prompt penicillin treatment after a positive test result may shorten the duration of pharyngitis in infected children. High rates of acute rheumatic fever (over 5 X 10(-4] and low medication compliance change the best strategy to agglutination test with intramuscular administration of penicillin.
尽管在过去几十年中急性风湿热的发病率有所下降，但最近仍有一些疫情报告。针对A组链球菌的快速乳胶凝集试验似乎相当准确，急性咽炎的早期治疗似乎会影响咽炎本身。这些因素导致了对目前咽痛患者最佳治疗方案的不确定性。
采用临床决策分析比较对症治疗、口服和肌内注射青霉素作为治疗选择，以及咽拭子培养和快速乳胶凝集试验作为诊断策略的风险和益处。将链球菌性咽炎的风险、其并发症、带菌率、诊断试验的准确性、抗生素治疗的疗效、过敏反应、用药依从性和健康结果的最佳估计值综合纳入一份管理建议中。所有结果都进行了敏感性分析，以检验其在假设合理变化情况下的稳健性。使用质量调整生命天数（QALD）损失作为结果指标。
对于携带链球菌风险为0.60的典型儿童，凝集试验联合口服青霉素产生的QALD预期损失最低（0.50）。然而，其他策略产生的损失仅比QALD高百分之几。
对于携带链球菌可能性至少为40%且在开始治疗前症状持续时间少于2天的儿童，诊断检测和口服青霉素处方似乎是初始管理的最佳选择。快速乳胶凝集试验比咽拭子培养更有效，因为检测结果呈阳性后立即使用青霉素治疗可能会缩短感染儿童咽炎的持续时间。急性风湿热高发病率（超过5×10⁻⁴）和低用药依从性会将最佳策略改为凝集试验联合肌内注射青霉素。
