By Philip R. Fischer, MD, DTM&H

Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN

Dr. Fischer reports no financial relationships relevant to this field of study.

SYNOPSIS: Testing for streptococcal pharyngitis in children younger than 3 years of age is rarely helpful and results in unnecessary costs. Quality improvement efforts can be effective in systematically reducing non-indicated testing.

SOURCE: Ahluwalia T, Jain S, Norton L, et al. Reducing streptococcal testing in patients < 3 years old in an emergency department. Pediatrics 2019;144:e20190174.

Colleagues at an urban tertiary children’s hospital emergency department in the mid-United States realized that streptococcal pharyngitis is rare in children younger than 36 months of age and that rheumatic fever, a complication of group A streptococcal infection, also is very rare. They knew that experts suggest not testing for streptococcal infection in children with a sore throat prior to age 3 years except in unusual situations. However, they noted that about 20 tests for streptococcal pharyngitis were conducted each month on children younger than 3 years of age. Identifying this as a gap between accepted standards of care and their own group’s practice, they undertook a quality improvement project.

Ahluwalia and colleagues assembled a multidisciplinary team including nurses, nurse practitioners, physician trainees, emergency medicine staff physicians, and pediatric infectious disease specialist physicians. They identified several factors that prompted testing of children younger than 3 years of age for streptococcal throat infection (lack of factual awareness, family expectation, and adult practice patterns). They provided education for clinicians through formal meetings, hallway discussions, electronic messages, and handouts. They informed nurses about the age-related (non) indications for streptococcal testing in young children. (In their setting, standing orders empowered nurses to submit swabs for testing prior to the visit with a clinician.) They provided visual reminders about the number of throat swabs being submitted for testing from children younger than 36 months of age. “Pop-up” reminders of the appropriate testing guidelines were inserted into the electronic ordering system whenever someone attempted to order unnecessary tests. Finally, written educational material about streptococcal infections and testing was provided for family members.

Outcome data that were gathered systematically included the number of streptococcal tests done prior to age 3 years, the number of patient/family complaints with their care, and the number of subsequent follow-up visits for complications.

During the 12 months prior to implementation of the intervention, 242 streptococcal tests were performed on children younger than 3 years of age. Nurse practitioners accounted for ordering more than two-thirds of the tests. Most tests (77%) were performed between 24 and 36 months of age, with the others performed between 12 and 24 months of age.

During the 10 months of the intervention, the rate of testing in young children dropped by 52%. Overall, 43% of the tests were done for appropriate indications (sore throat and fever in the absence of cough and runny nose AND contact with someone with documented streptococcal pharyngitis). Family desire prompted 23% of the tests. Tests were positive in 27% of cases, but fewer than half of the positive results came from children who met actual criteria for testing. One family complained about not being tested (after another physician elsewhere subsequently tested and obtained a positive result). No complications of treatment or non-treatment were identified. The reduced rate of testing and lack of adverse outcomes (medical or family dissatisfaction) were sustained over a subsequent eight months.

The investigators believed that part of their success was because they instituted an interdisciplinary culture change through education before they implemented a process change (electronic alerts during the ordering process). Although cost was not a primary driver or outcome measure, the authors retrospectively estimated that their intervention led to a $2,200 reduction in monthly costs.

COMMENTARY

A 2010 meta-analysis showed that 37% of children presenting with sore throat who underwent streptococcal testing had positive results, in contrast to the 12% of asymptomatic children who carried group A Streptococcus in their throats.1 The prevalence of group A Streptococcus in the throats of symptomatic children younger than 5 years of age was 24% (including three relevant studies involving young children in the meta-analysis), but further stratification for younger children was not done.1 However, the rate of positivity likely would have been higher if, following current guidelines, testing had been limited to children with sore throat and fever who did not have concurrent cough and runny nose.

Current guidelines suggest that over-testing and over-treatment can be avoided without undue risk of missed diagnoses by not testing children of any age who have cough, runny nose, hoarse voice, or oral ulcers.2 Further, current guidelines suggest that streptococcal testing is not indicated for children younger than 3 years of age since rheumatic fever is so rare and true streptococcal infection is so uncommon.2 However, the guidelines from the Infectious Disease Society of America allow consideration of testing (with less evidence of utility) if the child younger than 3 years of age has fever and sore throat along with risk factors, such as having an older sibling with documented group A Streptococcus infection.2

As suggested in a recent review article, “indis-criminate testing can lead to inappropriate antibiotic use.”3 Judicious antimicrobial stewardship begins with appropriate use of diagnostic testing.

The adage suggests that an old dog cannot be taught new tricks. Fortunately, as Ahluwalia and colleagues capably showed, practice habits can change — with multidisciplinary team effort, good education, and acceptable prompts and reminders. Staff and families can accept new care practices. More appropriate testing leads to more appropriate antibiotic use, with fewer complications and decreased cost.

REFERENCES

  1. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: A meta-analysis. Pediatrics 2010;126:e557-e564.
  2. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55:1279-1282.
  3. Homme JH. Acute otitis media and group A streptococcal pharyngitis: A review for the general pediatric practitioner. Pediatr Ann 2019;48:e343-e348