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Editor's Correspondence |

Acute Pharyngitis: No Reliability of Rapid Streptococcal Tests and Clinical Findings

Jan Matthys, MD; Marc De Meyere, MD
Arch Intern Med. 2006;166(20):2285. doi:10.1001/archinte.166.20.2285-a.
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In their article, Humair et al1 recommend the use of the streptococcal test and Centor criteria as valid tests for the diagnosis of pharyngitis in adults. After consulting the Internet guidelines on acute sore throat (see “Additional Information” at the end of this letter), we cannot share their opinion for the following reasons:

  • The Centor criteria (fever ≥38.5°C, absence of cough, tonsillar exudate, and enlarged cervical glands) are only used in 4 guidelines (3 American and 1 Canadian) and not in most of the European guidelines. This is mainly because in the logistic regression analysis that Centor conducted himself, he found that the prevalence of streptococci when 1, 2, 3, and 4 criteria were present were 6.5%, 15%, 32%, and 56%, respectively. Thus, even when the 4 criteria of Centor are present, the chance of a streptococci infection is nearly the same as a coin toss (56%).2

  • There is no international consensus on the use of the rapid streptococcal test (rapid antigen test): it is recommended in the American guidelines and in 1 European guideline (Finland). The streptococcal test is not recommended in the guidelines of England, Belgium, the Netherlands, Canada, and Scotland. These guidelines state that the predictive value of the test is too low, given the prevalence of streptococcal carriers (between 5% and 20%). Another reason is a modest sensitivity of the streptococcal test (most streptococcal tests have a sensitivity of about 80%-85% in primary health care, but not 90%).35

  • There is no consensus on the use of a throat culture. A throat culture is still recommended in different American guidelines and the Canadian and Finnish guidelines. Cultures are recommended when the streptococcal test result is negative or not commonly available. According to the guidelines of France, the Netherlands, Belgium, England, and Scotland and in 1 American guideline, results from a throat culture arrive too late to significantly influence the clinical course and are therefore not used.

  • In most of the European guidelines, acute sore throat is considered a self-limiting disease, and antibiotics are not commonly recommended. This is in accordance with European randomized clinical trials6 and the Cochrane review. Antibiotics (penicillin) provide only moderate clinical benefits in a minority of patients with pharyngitis, which is a self-limiting disease with low complication rates. Because antibiotics are only reserved for patients at risk (5% or less), there is no need for a streptococcal test in acute pharyngitis.

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