Ukrainian Journal of Perinatology and Pediatrics. 2023. 1(93): 37-44; doi 10.15574/PP.2023.93.37
Koloskova O. K.¹, Kosakovskyi A. L.², Ivanova L. A.¹, Horbatiuk I. B.^1
1Bukovynian State Medical University, Chernivtsi, Ukraine
²Shupyk National Healthcare University of Ukraine, Kyiv

For citation: Koloskova OK, Kosakovskyi AL, Ivanova LA, Horbatiuk IB. (2023). Clinical scale of severity of the course of acute tonsillopharyngitis in children: justification and diagnostic possibilities. Ukrainian Journal of Perinatology and Pediatrics. 1(93): 37-44; doi 10.15574/PP.2023.93.37.
Article received: Dec 30, 2022. Accepted for publication: Mar 13, 2023.

Purpose – to develop a simple, constellational clinical system for assessing the severity of the course of acute tonsillopharyngitis (ATP) in children to optimize etiotropic treatment by reducing unreasonable antibiotic therapy.
Materials and methods. We observed 102 children with ATP. A developed scale for assessing the severity of the course of ATP was used to monitor children. Evaluation of clinical symptoms with calculation of points was carried out daily, during 7 days of inpatient treatment. For the purpose of comparative analysis, as a "golden" standard, we used the assessment of symptoms of ATP according to the McIssac scale. A rapid test manufactured by Dectra Pharm (France) – Streptatest was used to verify the etiology of ATP caused by group A β-hemolytic streptococcus.
Results. Indicators of the diagnostic value of the developed severity scale in establishing the streptococcal etiology of ATP (score ≥45 points) exceed the McIsaac scale score (sum of points ≥4), in particular, sensitivity – 85.7% (vs. 77.1%), specificity – 76.1% (against 31.3%), positive predicted value 78.2% (against 52.8%), negative predicted value – 84.2% (against 57.7%).
The total score on the severity scale, which is 45 points or more, significantly increases the risk of ATP caused by β-hemolytic streptococcus of group A: odds ratio (OR) – 19.0, relative risk (RR) – 4.94, absolute risk (AR) – 0.62, which can be considered an indication for appointment of antibacterial therapy for hospitalized patients. A total score of ≥35 points on the 3rd day of inpatient treatment, is associated with a statistically significant risk of the absence of streptococcal infection of the oropharynx, and therefore is an indication to cancel the use of antibiotics: OR – 2.3, RR – 1.45, AR – 0.2.
Conclusions. The developed scale of the severity of the course of ATP allows to extend the first 3 days to statistically reliably detect a more pronounced inflammatory process caused by Str. Pyogenes and optimize tactics of etiotropic therapy. This constellation system is especially useful in conditions of limited resources and the impossibility of using rapid Streptatests, when obtaining dubious or contradictory results of the McIsaac scale assessment, or when applying the strategy of delayed appointment of antimicrobial agents.
The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the institution mentioned in the paper. The informed consent of the patient was obtained for conducting the studies.
No conflict of interests was declared by the authors.
Keywords: children, acute tonsillopharyngitis, etiology, group A β-hemolytic streptococcus, severity scale.

REFERENCES

1. Dubois C, Smeesters PR, Refes Y, Levy C, Bidet P, Cohen R et al. (2021, Dec). Diagnostic accuracy of rapid nucleic acid tests for group A streptococcal pharyngitis: systematic review and meta-analysis. Clin Microbiol Infect. 27 (12): 1736-1745. Epub 2021 May 6. https://doi.org/10.1016/j.cmi.2021.04.021; PMid:33964409

2. Christensen AM, Thomsen MK, Ovesen T, Klug TE. (2014). Are procalcitonin or other infection markers useful in the detection of group A streptococcal acute tonsillitis? Scand J Infect Dis. 46: 376-383. https://doi.org/10.3109/00365548.2014.885656; PMid:24606046

3. Cohen JF, Bertille N, Cohen R, Chalumeau M. (2016, Jul 4). Rapid antigen detection test for group A streptococcus in children with pharyngitis. Cochrane Database Syst Rev. 7 (7): CD010502. PMID: 27374000; PMCID: PMC6457926. https://doi.org/10.1002/14651858.CD010502.pub2

4. Fine AM, Nizet V, Mandl KD. (2012). Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 172: 847-852. https://doi.org/10.1001/archinternmed.2012.950; PMid:22566485 PMCid:PMC3627733

5. Joachim L, Campos D Jr, Smeesters PR. (2010, Sep). Pragmatic scoring system for pharyngitis in low-resource settings. Pediatrics. 126 (3): e608-614. Epub 2010 Aug 9. https://doi.org/10.1542/peds.2010-0569; PMid:20696724

6. Koloskova OK, Bezrukov LO, Ivanova LA, Horbatiuk IB, Horbatiuk IB. (2019). Optimization of clinical diagnosis and treatment of acute tonsillopharyngitis in children. Arch Balk Med Union. 54 (1): 51-56. https://doi.org/10.31688/ABMU.2019.54.1.07

7. Krüger K, Töpfner N, Berner R, Windfuhr J, Oltrogge JH et al. (2021, Mar 19). Clinical Practice Guideline: Sore Throat. Dtsch Arztebl Int. 118 (11): 188-194. https://doi.org/10.3238/arztebl.m2021.0121; PMid:33602392 PMCid:PMC8245861

8. Le Marechal F, Martinot A, Duhamel A, Pruvost I, Dubos F. (2013, Mar 9). Streptococcal pharyngitis in children: a meta-analysis of clinical decision rules and their clinical variables. BMJ Open. 3 (3): e001482. https://doi.org/10.1136/bmjopen-2012-001482; PMid:23474784 PMCid:PMC3612811

9. Linder JA, Bates DW, Lee GM et al. (2005). Antibiotic treatment of children with sore throat. JAMA. 294: 2315-2322. https://doi.org/10.1001/jama.294.18.2315; PMid:16278359

10. Little P, Hobbs FD, Mant D, McNulty CA, Mullee M et al. (2012). Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study. Br J Gen Pract. 62: e787-e794. https://doi.org/10.3399/bjgp12X658322; PMid:23211183 PMCid:PMC3481520

11. Little P, Hobbs FD, Moore M et al. (2013, Oct 10). Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ. 347: f5806. Erratum in: BMJ. 2018 Mar 5; 360: k1068. https://doi.org/10.1136/bmj.f5806; PMid:24114306 PMCid:PMC3805475

12. Little P, Hobbs FD, Moore M et al. (2014). Primary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess. 18; VII-XXV: 1-101. https://doi.org/10.3310/hta18060; PMid:24467988 PMCid:PMC4781545

13. Miller KM, Tanz RR, Shulman ST, Carapetis JR, Cherian T, Lamagni T et al. (2022, Sep 15). Standardization of Epidemiological Surveillance of Group A Streptococcal Pharyngitis. Open Forum Infect Dis. 9 (1): S5-S14. https://doi.org/10.1093/ofid/ofac251; PMid:36128410 PMCid:PMC9474939

14. O'Sullivan JW, Harvey RT, Glasziou PP, McCullough A. (2016, Nov 25). Written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care. Cochrane Database Syst Rev. 11 (11): CD011360. PMCID: PMC6464519. https://doi.org/10.1002/14651858.CD011360.pub2; PMid:27886368

15. Pavez D, Pérez R, Cofré J, Rodríguez J. (2019, Feb). Recommendations for diagnosis and etiological treatment of acute streptococcal pharyngotonsilitis in pediatrics. Rev Chilena Infectol. 36 (1): 69-77. Spanish. https://doi.org/10.4067/S0716-10182019000100069; PMid:31095205

16. Scheel A, Beaton AZ, Katzenellenbogen J, Parks T, Miller KM, Cherian T et al. (2022, Sep 15). Standardization of Epidemiological Surveillance of Acute Rheumatic Fever. Open Forum Infect Dis. 9 (1): S41-S49. https://doi.org/10.1093/ofid/ofac252; PMid:36128408 PMCid:PMC9474936

17. Shulman ST, Bisno AL, Clegg HW et al. (2012). 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. 55: 1279-1282. https://doi.org/10.1093/cid/cis847; PMid:23091044

18. Singh XS, Dolan JG, Centor RM. (2006, Mar 13). Optimal management of adults with pharyngitis – a multi-criteria decision analysis. BMC Med Inform Decis Mak. 6: 14. https://doi.org/10.1186/1472-6947-6-14; PMid:16533386 PMCid:PMC1431519

19. Stelter K. (2014, Mar). Tonsillitis and sore throat in childhood. Laryngorhinootologie. 93 (1): S84-102. German. Epub 2014 Apr 7. PMID: 24710788. https://doi.org/10.1055/s-0033-1363210

20. Stjernquist-Desatnik A, Orrling A. (2009, Feb). Pharyngotonsillitis. Periodontol 2000. 49 (1): 140-150. https://doi.org/10.1111/j.1600-0757.2008.00282.x; PMid:19152531 PMCid:PMC7167632

21. Suzumoto M, Hotomi M, Billal DS, Fujihara K, Harabuchi Y, Yamanaka N. (2009, Jun). A scoring system for management of acute pharyngo-tonsillitis in adults. Auris Nasus Larynx. 36 (3): 314-320. Epub 2008 Sep 5. https://doi.org/10.1016/j.anl.2008.07.001; PMid:18774249 PMCid:PMC7126418

22. Togawa A, Hotomi M, Tamura S, Yamanaka N. (2011). Clinical scoring system of acute pharyngotonsillitis. Adv Otorhinolaryngol. 72: 139-141. Epub 2011 Aug 18. https://doi.org/10.1159/000324771; PMid:21865713

23. Wang D, Liu C, Zhang X, Liu C. (2021, Mar 25). Does diagnostic uncertainty increase antibiotic prescribing in primary care? NPJ Prim Care Respir Med. 31 (1): 17. https://doi.org/10.1038/s41533-021-00229-9; PMid:33767206 PMCid:PMC7994848

24. Wi D, Choi SH. (2021). Positive Rate of Tests for Group a Streptococcus and Viral Features in Children with Acute Pharyngitis. Children (Basel). 8 (7): 599-607. https://doi.org/10.3390/children8070599; PMid:34356578 PMCid:PMC8304790

25. Windfuhr JP, Toepfner N, Steffen G, Waldfahrer F, Berner R. (2016, Apr). Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management. Eur Arch Otorhinolaryngol. 273 (4): 973-987. Epub 2016 Jan 11. https://doi.org/10.1007/s00405-015-3872-6; PMid:26755048 PMCid:PMC7087627

26. Windfuhr JP, Toepfner N, Steffen G, Waldfahrer F, Berner R. Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management. Eur Arch Otorhinolaryngol. 2016 Apr;273(4):973-87. Epub 2016 Jan 11. https://doi.org/10.1007/s00405-015-3872-6; PMid:26755048 PMCid:PMC7087627

27. Yao J, Zhang Y, Wang XZ, Zhao J, Yang ZJ, Lin YP et al. (2022, Feb 16). Flavonoids for Treating Viral Acute Respiratory Tract Infections: A Systematic Review and Meta-Analysis of 30 Randomized Controlled Trials. Front Public Health. 10: 814669. https://doi.org/10.3389/fpubh.2022.814669; PMid:35252093 PMCid:PMC8888526