Guideline:
Acute pharyngitis in children
Bibliographic Source(s)
- Michigan Quality Improvement Consortium. Acute pharyngitis in children. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Jan. 1 p.
Guideline Status
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.
Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Treatment
Intended Users
Advanced Practice Nurses
Health Plans
Physician Assistants
Physicians
Guideline Objective(s)
- To achieve significant measurable improvements in the assessment diagnosis and treatment of acute pharyngitis through the development and implementation of common evidence-based clinical practice guidelines
- To design concise guidelines that are focused on key management components of acute pharyngitis to improve outcomes
Target Population
High-risk and not high-risk children and adolescents 2 to 18 years of age
Interventions and Practices Considered
Assessment/Diagnosis
- Assessment of past history of rheumatic fever or household contact with a history of rheumatic fever
- Assessment of the likelihood of strep pharyngitis
- Throat culture (TC) or Rapid Screen test
Management/Treatment
- Throat culture or Rapid Screen negative: symptomatic treatment avoid antibiotics
- Strep pharyngitis:
- Penicillin VK
- Amoxicillin
- Benzathine penicillin G
- Erythromycin ethyl succinate if penicillin allergic
- Alternative treatment: cephalexin
- Re-evaluation and referral to otolaryngologist if necessary
Major Outcomes Considered
Not stated
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The Michigan Quality Improvement Consortium (MQIC) project leader conducts a search of current literature in support of the guideline topic. Computer database searches are used to identify published studies and existing protocols and/or clinical practice guidelines on the selected topic. A database such as MEDLINE and two to three other databases are used.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence for the Most Significant Recommendations
- Randomized controlled trials
- Controlled trials no randomization
- Observational studies
- Opinion of expert panel
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Using the health plan guideline summaries and information obtained from the literature search the Michigan Quality Improvement Consortium (MQIC) director and/or project leader prepare a draft guideline for review by the MQIC Medical Directors.
The draft guideline and health plan guideline summaries are distributed to the MQIC Medical Directors for review and discussion at their next committee meeting.
The review/revision cycle may be conducted over several meetings before consensus is reached. Each version of the draft guideline is distributed to the MQIC Medical Directors Measurement and Implementation Committee members for review and comments. All feedback received is distributed to the entire membership.
Once the MQIC Medical Directors achieve consensus on the draft guideline it is considered approved for external distribution to practitioners with review and comments requested.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
Once the Michigan Quality Improvement Consortium (MQIC) Medical Directors achieve consensus on the draft guideline it is considered approved for external distribution to practitioners with review and comments requested.
The MQIC director also forwards the approved guideline draft to presidents of the appropriate state medical specialty societies for their input. All feedback received from external reviews is presented for discussion at the next MQIC Medical Directors Committee meeting. In addition physicians are invited to attend the committee meeting to present their comments.
Major Recommendations
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Assessment
Assess past history of rheumatic fever (especially carditis or valvular disease) or household contact with a history of rheumatic fever to identify high-risk patients.
Assess the likelihood of strep pharyngitis using the following items:
- Sudden onset
- Sore throat
- Fever
- Patchy discrete exudate
- Headache
- Nausea vomiting and abdominal pain
- Inflammation of pharynx and tonsils
- Tender enlarged anterior cervical nodes
- Patient aged 5–15 years
- Presentation in winter or early spring
- History of exposure
Diagnosis
Not High-Risk Patients
Probability of group A beta hemolytic streptococci (GABHS): Low
Testing: None
Treatment: Symptomatic treatment only. Avoid antibiotics.
Probability of GABHS: Intermediate or High
Testing: Throat Culture (TC) OR Rapid Screen
Treatment: If TC is positive use antibiotics.
If TC is negative use symptomatic treatment only. Avoid antibiotics.
If treatment is started and culture result is negative stop antibiotics.
If Rapid Screen is positive use antibiotics.
If Rapid Screen is negative culture1 and only use antibiotics if throat culture is positive.
1Culture optional for age 16 and over
High Risk Patients (history of rheumatic fever or household contact)
Start antibiotics immediately. If throat culture is obtained and is negative stop antibiotics.
Treatment
Preferred Treatment for Strep Pharyngitis
- Penicillin VK: 250–500 mg twice or three times daily (bid-tid) x 10 days
- Amoxicillin: 20–40 mg/kg/day divided tid x 10 days [A]
- Benzathine penicillin G intramuscularly (IM) x 1: 600000 units for weight <60 lbs; 1.2 million units for weight> 60 lbs
- If allergic to penicillin: erythromycin ethyl succinate: 40 mg/kg/day two-four times daily (bid-qid) (max 1 g/day) x 10 days
- With oral antibiotics a full 10 day course is required
Alternative Treatment for Strep Pharyngitis
- Cephalexin 15 to 50 mg/kg/day divided bid or tid x 10 days
Re-Evaluate/Referral
- If failure to respond clinically after 48 hours of treatment rule out peritonsillar or retropharyngeal abscess. If present prompt otolaryngology (ENT) evaluation is recommended.
- Assess the potential for a compliance problem.
Definitions:
Levels of Evidence for the Most Significant Recommendation
- Randomized controlled trials
- Controlled trials no randomization
- Observational studies
- Opinion of expert panel
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of evidence is provided for the most significant recommendations (see "Major Recommendations" field).
This guideline is based on several sources including the ICSI Acute Pharyngitis Guideline Institute for Clinical Systems Improvement 2005 (www.icsi.org).
Potential Benefits
Through a collaborative approach to developing and implementing common clinical practice guidelines and performance measures for assessment diagnosis and treatment of acute pharyngitis in children Michigan health plans will achieve consistent delivery of evidence-based services and better health outcomes. This approach also will augment the practice environment for physicians by reducing the administrative burdens imposed by compliance with diverse health plan guidelines and associated requirements.
Potential Harms
Not stated
Qualifying Statements
This guideline lists core management steps. Individual patient considerations and advances in medical science may supersede or modify these recommendations.
Description of Implementation Strategy
When consensus is reached on a final version of the guideline a statewide mailing of the approved guideline is completed. The guideline is distributed to physicians in the following medical specialties:
- Family Practice
- General Practice
- Internal Medicine
- Other Specialists for which the guideline is applicable (e.g. endocrinologists allergists pediatricians cardiologists)
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Bibliographic Source(s)
- Michigan Quality Improvement Consortium. Acute pharyngitis in children. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Jan. 1 p.
Adaptation
This guideline is based on several sources including the ICSI Acute Pharyngitis Guideline Institute for Clinical Systems Improvement 2005 (www.icsi.org).
Source(s) of Funding
Michigan Quality Improvement Consortium
Guideline Committee
Michigan Quality Improvement Consortium Medical Director's Committee
Composition of Group that Authored the Guideline
Physician representatives from participating Michigan Quality Improvement Consortium health plans Michigan State Medical Society Michigan Osteopathic Association Michigan Association of Health Plans Michigan Department of Community Health and Michigan Peer Review Organization
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.
Guideline Availability
Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the Michigan Quality Improvement Consortium Web site.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on November 28 2005. The updated information was verified by the guideline developer on December 19 2005. This NGC summary was updated by ECRI on October 16 2006. The updated information was verified by the guideline developer on November 3 2006. This NGC summary was updated by ECRI Institute on July 11 2007. The updated information was verified by the guideline developer on July 16 2007.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which may be reproduced with the citation developed by the Michigan Quality Improvement Consortium.
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