Steinhoff M C, Abd el Khalek M K, Khallaf N, Hamza H S, el Ayadi A, Orabi A, Fouad H, Kamel M
Department of International Health, School of Hygiene and Public Health, Baltimore MD, USA.
Lancet. 1997 Sep 27;350(9082):918-21. doi: 10.1016/s0140-6736(97)03317-5.
Primary prevention of acute rheumatic fever requires antibiotic treatment of acute streptococcal pharyngitis. In developing countries, clinicians must rely on clinical guidelines for presumptive treatment of streptococcal pharyngitis since bacterial culture and rapid diagnostic tests are not feasible. We evaluated the WHO Acute Respiratory Infection guideline in a large urban paediatric clinic in Egypt.
Children between 2 and 13 years of age who had a sore throat and pharyngeal erythema were enrolled in the study. Clinical, historical, and demographic information was recorded and a throat culture for group A beta-haemolytic streptococci was done. Sensitivity (% of true-positive throat cultures) and specificity (% of true-negative throat cultures) were calculated for each clinical feature. The effect of various guidelines on correct presumptive treatment for throat-culture status was calculated.
Of 451 children with pharyngitis, 107 (24%) had group A beta-haemolytic streptococci on throat culture. A purulent exudate was seen in 22% (99/450) of these children and this sign was 31% sensitive and 81% specific for a positive culture. The WHO Acute Respiratory Infections (ARI) guidelines, which suggest treatment for pharyngeal exudate plus enlarged and tender cervical node, were 12% sensitive and 94% specific; 13/107 children with a positive throat culture would correctly receive antibiotics and 323/344 with a negative throat culture would, correctly, not receive antibiotics. Based on our data we propose a modified guideline whereby exudate or large cervical nodes would indicate antibiotic treatment, and this guideline would be 84% sensitive and 40% specific; 90/107 children with a positive throat culture would correctly receive antibiotics and 138/344 with a negative throat culture would, correctly, not receive antibiotics.
The WHO ARI clinical guideline has a high specificity but low sensitivity that limits the unnecessary use of antibiotics, but does not treat 88% of children with a positive streptococcal throat culture who are at risk of acute rheumatic fever. A modified guideline may be more useful in this population. Prospective studies of treatment guidelines from many regions are needed to assess their use since the frequency of pharyngitis varies.
急性风湿热的一级预防需要对急性链球菌性咽炎进行抗生素治疗。在发展中国家，由于细菌培养和快速诊断检测不可行，临床医生必须依靠临床指南对链球菌性咽炎进行推定治疗。我们在埃及一家大型城市儿科诊所评估了世界卫生组织（WHO）的急性呼吸道感染指南。
纳入2至13岁出现咽喉疼痛和咽部红斑的儿童。记录临床、病史和人口统计学信息，并进行A组β溶血性链球菌的咽拭子培养。计算每个临床特征的敏感性（咽拭子培养真阳性的百分比）和特异性（咽拭子培养真阴性的百分比）。计算各种指南对根据咽拭子培养结果进行正确推定治疗的效果。
在451例咽炎患儿中，107例（24%）咽拭子培养发现A组β溶血性链球菌。这些患儿中有22%（99/450）出现脓性渗出物，该体征对培养阳性的敏感性为31%，特异性为81%。WHO急性呼吸道感染（ARI）指南建议对咽部渗出物加颈部淋巴结肿大且触痛进行治疗，其敏感性为12%，特异性为94%；107例咽拭子培养阳性的患儿中有13例将正确接受抗生素治疗，344例咽拭子培养阴性的患儿中有323例将正确不接受抗生素治疗。根据我们的数据，我们提出一项修改后的指南，即渗出物或颈部大淋巴结提示应进行抗生素治疗，该指南的敏感性为84%，特异性为40%；107例咽拭子培养阳性的患儿中有90例将正确接受抗生素治疗，344例咽拭子培养阴性的患儿中有138例将正确不接受抗生素治疗。
WHO的ARI临床指南特异性高但敏感性低，这限制了抗生素的不必要使用，但未对88%有链球菌性咽拭子培养阳性且有急性风湿热风险的患儿进行治疗。修改后的指南可能对该人群更有用。由于咽炎的发病率各不相同，需要对许多地区的治疗指南进行前瞻性研究以评估其适用性。
