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Editor's Correspondence |

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

Jean-Paul Humair, MD, MPH; Sylvie Antonini Revaz, MD; Patrick Bovier, MD, MPH; Hans Stalder, MD
Arch Intern Med. 2006;166(20):2285-2286. doi:10.1001/archinte.166.20.2285-b.
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In reply

Matthys and De Meyere disagree with the conclusion of our article that combining clinical findings and a rapid streptococcal test is a valid approach for the management of pharyngitis in adults.1 However, several reasons justify that it is an efficient strategy to identify and treat adequately the few patients with pharyngitis who need antibiotic therapy:

  • We agree that clinical findings alone are unreliable to diagnose streptococcal pharyngitis. Our study included only patients meeting 2 to 4 clinical criteria, corresponding with a 24% to 60% probability of streptococcal pharyngitis. This diagnostic uncertainty creates a typical situation in which a diagnostic test significantly changes the posttest probability of streptococcal infection and reduces unnecessary antibiotic prescribing.

  • As discussed in our article, sensitivity and positive predictive value of rapid streptococcal tests vary between studies, while all studies agree on a high specificity greater than 95%.2 The positive predictive value depends on the prevalence of the disease, which is related to population characteristics such as age, clinical features, and health care setting. There is also a spectrum bias as sensitivity increases with the clinical score, which is related to the inoculum size.3 In all studies, there was a lower prevalence of streptococcal pharyngitis among patients than in ours, but most included only or mainly children with high rates of streptococcal carriage and patients with sore throat regardless of the clinical score. In our study, we included only adults with a higher prevalence of streptococcal pharyngitis to precisely improve the positive predictive value of the rapid streptococcal test.

  • We fully agree with European guidelines and do not support a strategy based on throat culture for the diagnosis of pharyngitis because late results do not change the clinical decision nor the course of the disease in clinical practice. Our study also shows that this strategy is twice more expensive and does not improve the diagnosis.

  • Although streptococcal pharyngitis is usually self-limited with low complication rates, antibiotic therapy reduces by 1 day the duration of symptoms as well as the spread of the disease and the risk of suppurative complications.4 Symptom relief and resuming daily activities happen more quickly for patients with streptococcal pharyngitis receiving treatment with penicillin.4 These benefits are small for individual patients but may be substantial for a frequent condition in a population; reducing duration and complications could also improve quality of life and work capacity and decrease costs.

  • Many clinicians, including infectious diseases specialists, are concerned by the low sensitivity of the rapid test and some recommend a throat culture when rapid test results are negative. Their dilemma between treatment after testing and empirical treatment results in overprescription of antibiotics, despite European guidelines recommending no treatment.5 Because it significantly modifies the probability of streptococcal pharyngitis and antibiotic prescription at a reasonable cost, the rapid streptococcal test is an effective and simple tool to limit antibiotic overuse.

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