Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis

Robertson, Katharine A; Volmink, Jimmy; Mayosi, Bongani M.

doi:10.1186/1471-2261-5-11

Cited by 172 publications

(119 citation statements)

References 24 publications

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“…43 Although localized outbreaks have occurred in recent decades, the incidence of rheumatic fever in most developed countries has declined dramatically. 44 Some of this decline might be attributable to better recognition and antibiotic treatment, 45 but more likely this relates to a decline in the prevalence of rheumatogenic strains of GAS. 46 Antibiotics may also have a role in preventing suppurative complications associated with GAS pharyngitis, such as peritonsillar abscess (PTA), AOM, and acute sinusitis.…”

Section: Benefitsmentioning

confidence: 99%

Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics

Hersh¹,

Jackson²,

Hicks³

et al. 2013

Pediatrics

235

199

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Most upper respiratory tract infections are caused by viruses and require no antibiotics. This clinical report focuses on antibiotic prescribing strategies for bacterial upper respiratory tract infections, including acute otitis media, acute bacterial sinusitis, and streptococcal pharyngitis. The principles for judicious antibiotic prescribing that are outlined focus on applying stringent diagnostic criteria, weighing the benefits and harms of antibiotic therapy, and understanding situations when antibiotics may not be indicated. The principles can be used to amplify messages from recent clinical guidelines for local guideline development and for patient communication; they are broadly applicable to antibiotic prescribing in general.

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Section: Benefitsmentioning

confidence: 99%

Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics

Hersh¹,

Jackson²,

Hicks³

et al. 2013

Pediatrics

235

199

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“…48 In these countries, there is a clear indication for treatment of GAS pharyngitis to prevent rheumatic fever and its chronic and disabling sequelae, rheumatic heart disease. 49 A highly sensitive ($95%) and inexpensive RADT with a very rapid turnaround time could make a major contribution to control efforts for rheumatic fever. Based on our data, however, no single test currently fulfills all 3 of these criteria.…”

Section: Figurementioning

confidence: 99%

Rapid Diagnostic Tests for Group A Streptococcal Pharyngitis: A Meta-analysis

et al. 2014

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BACKGROUND AND OBJECTIVE: Effective management of group A streptococcal (GAS) pharyngitis is hindered by impracticality of the gold standard diagnostic test: throat culture. Rapid antigen diagnostic tests (RADTs) are a promising alternative, although concerns about their sensitivity and specificity, and variation between test methodologies, have limited their clinical use. The objective of this study was to perform a systematic review with meta-analysis of the diagnostic accuracy of RADTs for GAS pharyngitis. METHODS:Medline and Embase from 1996 to 2013 were used as data sources. Of 159 identified studies, 48 studies of diagnostic accuracy of GAS RADTs using throat culture on blood agar as a reference standard were selected. Bivariate random-effects regression was used to estimate sensitivity and specificity with 95% confidence intervals (CIs). Additional meta-analyses were performed for pediatric data. RESULTS:A total of 60 pairs of sensitivity and specificity from 48 studies were included. Overall summary estimates for sensitivity and specificity of RADTs were 0.86 (95% CI 0.83 to 0.88) and 0.96 (95% CI 0.94 to 0.97), respectively, and estimates for pediatric data were similar. Molecular-based RADTs had the best diagnostic accuracy. Considerable variability exists in methodology between studies. There were insufficient studies to allow meta-regression/subgroup analysis within each test type.CONCLUSIONS: RADTs can be used for accurate diagnosis of GAS pharyngitis to streamline management of sore throat in primary care. RADTs may not require culture backup for negative tests in most low-incidence rheumatic fever settings. Newer molecular tests have the highest sensitivity, but are not true point-of-care tests. ABBREVIATIONS CI-confidence interval ELISA-enzyme-linked immunosorbent assay FISH-fluorescence in situ hybridization GAS-group A b-hemolytic streptococcus OIA-optical immunoassay PCR-polymerase chain reaction QUADAS-Quality Assessment of Diagnostic Accuracy Studies RADT-rapid antigen diagnostic test ROC-receiver operating characteristics S-ROC-summary receiver operating characteristics Dr. Lean collected data for the study and drafted the initial manuscript; Dr Arnup carried out the statistical analyses and reviewed and revised the manuscript; Drs Danchin and Steer conceptualized the study, supervised data collection, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.www.pediatrics.org/cgi

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“…Overall, adverse reactions to antibiotics occur in 5% to 25% of patients. 10 The rate of anaphylactic reactions is 1 in 400 prescriptions, 9 and there is a 0.3% chance of death from anaphylaxis. 12 Thus, what are the expected harms if we treat 5 million children with antibiotics for their strep throat to prevent 1 death from RHD?…”

mentioning

confidence: 99%

“…A meta-analysis published in 2005 reported a much smaller NNT of 53 to prevent ARF. 9 These data included 10 studies; 8 of those were conducted in young adult male subjects living on military bases in the United States from 1950 to 1961 when there were much higher rates of ARF nationwide. Similar to our NNT calculation, Newman 10 demonstrates the same point by highlighting a 1940s military study population in whom ARF had an incidence of 438 per 100 000, which is 5000 times the incidence of ARF seen today.…”

mentioning

confidence: 99%

Taking Chances With Strep Throat

McMurray

Garber

2015

Hospital Pediatrics

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A previously healthy 22-month-old male child presented in the summer to his pediatrician' s office with an acute febrile illness. Results of the physical examination were normal except for rhinorrhea, but because of the fever, the pediatrician performed a rapid antigen strep test. The test result was positive, and 10 days of amoxicillin/clavulanic acid were prescribed. After 7 days on the antibiotic, the patient developed a diffuse, erythematous rash on his trunk and extremities; he was taken to the emergency department, where he was prescribed oral steroids for the rash. The following morning, his pediatrician diagnosed the rash as a drug reaction and discontinued the amoxicillin/clavulanic acid and started azithromycin to complete the treatment course for group A streptococcus (GAS) pharyngitis or "strep throat." The following day, the patient' s rash became more widespread and pruritic. A third visit with the pediatrician was scheduled, and erythema multiforme was diagnosed. The patient was nontoxic appearing, but the pediatrician decided to admit him to complete the treatment course for strep throat along with possible intravenous steroids as therapy for the erythema multiforme. On admission, the patient was noted to have an impressive rash without oral or ocular involvement and was otherwise well-appearing. Ultimately, a tactful discussion with the admitting pediatrician revealed that the preferred course for all parties would be discontinuation of antibiotics and steroids, and the patient was then discharged from the hospital.In the practice of medicine, we should attempt to weigh the risks and benefits of each patient management decision. This particular case brings up various opportunities in which decisions might have been made differently if both the potential risks and benefits of the treatment were considered more explicitly. First, what were the chances that this child had strep throat? A positive rapid strep test result may indicate true infection or the carrier state (eg, colonization without infection) or laboratory error (eg, false-positive, mix-up with someone else' s test sample). GAS pharyngitis is most commonly observed in children aged 5 to 15 years in the winter and spring months. Our patient was aged ,2 years, did not have pharyngitis, and presented in the summer. The 2012 Infectious Diseases Society of America guidelines for the management of GAS pharyngitis do not recommend testing in those with clinical and epidemiologic factors strongly suggestive of viral etiology or in children ,3 years of age because the potential sequela (acute rheumatic fever [ARF]) is rare in children aged ,3 years.1 These recommendations are offered because development of ARF is believed to be secondary to repeated exposures to GAS that will effectively prime the immune system over time to create the autoimmune response leading to ARF; testing, therefore, at a young age is not of high value.Many pediatricians understand that the primary impetus to detect and treat strep throat is to prevent the harmful sequela ...

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Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis

Cited by 172 publications

References 24 publications

Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics

Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics

Rapid Diagnostic Tests for Group A Streptococcal Pharyngitis: A Meta-analysis

Taking Chances With Strep Throat

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