Park M, Hue V, Dubos F, Lagrée M, Pruvost I, Martinot A
Urgences pédiatriques, pôle urgence, CHRU Lille, 59000 Lille, France.
Arch Pediatr. 2013 Oct;20(10):1083-8. doi: 10.1016/j.arcped.2013.07.002. Epub 2013 Aug 8.
Rapid group A Streptococcus (GAS) antigen detection tests (RDT) have high diagnostic performance for the management of acute pharyngitis and are recommended before any antibiotic (ATB) prescription in France to reduce ATB use. The rate of general practitioners (GPs) using GAS RDT is low and decreasing. Our aims were to describe the reasons for pediatricians and GPs not using RDT or for prescribing ATB despite of a negative RDT.
In 2011, a survey was conducted in a random sample of 368 GPs plus all ambulatory pediatricians (n=82) in the Nord-Pas-de-Calais region of France.
Response rates were 74% (n=61) for pediatricians and 18% (n=68) for GPs. RDTs for pharyngitis were used by 75% [95% CI: 63-85] of pediatricians and 53% [95% CI: 41-64] of GPs (P<0.001). RDTs were systematically used in children 3years of age and older by only 59% of all physicians using RDTs. An ATB was systematically prescribed in case of positive RDT by 96% of physicians and eventually prescribed in case of negative RDT by 74%. The main reasons for ATB prescription in case of negative RDT were association with otitis media (51%), second visit for the same pharyngitis (45%), and high clinical suspicion of GAS pharyngitis (36%). Forty percent of non-RDT users had used them in the past. The 3 main reasons for not using RDT were the lack of time (57%), high confidence in clinical data to discriminate GAS pharyngitis (48%), and low confidence in RDT (27%).
This survey highlights the lack of knowledge about low and high discriminant values of clinical data and RDT, respectively, especially the excellent negative predictive value of RDTs, and an erroneous assessment of the low risk of missing GAS pharyngitis compared to the consequences of inappropriate ATB use.
A 组链球菌（GAS）快速抗原检测试验（RDT）在急性咽炎管理方面具有较高的诊断性能，在法国，建议在开具任何抗生素（ATB）处方前进行该检测，以减少抗生素的使用。全科医生（GP）使用 GAS RDT 的比例较低且呈下降趋势。我们的目的是描述儿科医生和全科医生不使用 RDT 的原因，以及尽管 RDT 结果为阴性仍开具 ATB 的原因。
2011 年，对法国北部加莱海峡地区的 368 名全科医生和所有门诊儿科医生（n = 82）进行了随机抽样调查。
儿科医生的回复率为 74%（n = 61），全科医生的回复率为 18%（n = 68）。75%[95%置信区间：63 - 85]的儿科医生和 53%[95%置信区间：41 - 64] 的全科医生使用咽炎 RDT（P < 0.001）。在所有使用 RDT 的医生中，只有 59% 的医生对 3 岁及以上儿童系统性地使用 RDT。96% 的医生在 RDT 结果为阳性时系统性地开具 ATB，74% 的医生在 RDT 结果为阴性时最终开具 ATB。RDT 结果为阴性时开具 ATB 的主要原因是与中耳炎有关（51%）、因同一咽炎再次就诊（45%）以及对 GAS 咽炎的临床高度怀疑（36%）。40% 的非 RDT 用户过去曾使用过。不使用 RDT 的三个主要原因是时间不足（57%）、对区分 GAS 咽炎的临床数据高度自信（48%）以及对 RDT 信心不足（27%）。
本次调查突出了对临床数据和 RDT 的低判别值和高判别值缺乏了解，特别是 RDT 的出色阴性预测值，以及与不适当使用 ATB 的后果相比，对漏诊 GAS 咽炎低风险的错误评估。
