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VIRAL PHARYNGITIS: IMPROVED DIAGNOSIS WITH

THE CENTOR CRITERIA

Dr. Monica Denning-Maldonado, APRN, FNP-C

Objectives

• Description of the clinical problem• Review of Literature• Explain theoretical framework adapted• Explain Quality Improvement Model

adapted • Discuss findings and outcomes• Implications for Nursing Practice

Clinical Reflective Journal

Conclusions Journal

• Most Common complaint

• Diagnosis

• Returned visits

• Overuse of strep tests

• No evidence-based guidelines

https://www.insidehighered.com/advice/2016/04/21/advice-getting-published-scholarly-journal-essay

Viral Pharyngitis

Introduction Pharyngitis

• Difficult

• Led to issues:

• Antibiotic overuse• Side effects • Increased costs• Antibiotic

resistance https://healthool.com/sore-throat-on-one-side/

Antibiotic Overuse

Centers for Disease Control and Prevention

On a global scale, WHO (2014) states:• Antibiotic resistance is

serious threat to global public health

World Health Organization

• 2 million people affected by antibiotic resistant infections

• Associated with 23,000 US deaths annually

(CDC, 2013)

• Pharyngitis leading Dx with 40% of unnecessary antibiotic Rx

(Fiore, Fettic, Wright, & Ferrara, 2018) https://www.youtube.com/

watch?v=SyxoAO6avFs

Antibiotic Expenditures

https://www.alternet.org/economy/pill-cures-hepatitis-costs-just-4-if-you-live-

america-its-1000

• 2010-2015 US antibiotic expenditures $56 billion

• One solution

(Suda et al., 2018)

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Misdiagnosis

• On-site Rapid Antigen Strep Tests

• Usual way

• Standard treatment plan

• Misled

• Seek additional care

• Healthcare system affected

http://bioplus.gr/en/products2012/rapid-tests/strep-a/

Providers reluctant

• Patient remarks

• Provider thoughts

• Patient wants

• Provider wantshttps://www.pinterest.com/pin/255931191294378190/

Literature Review

Centor Score

• Adds a criteria for age• Aged 3-14 add 1 point• Aged 45 or older subtract 1

point• Validated

• McIsaac, White, Tannenbaum, & Baum, 1998

• McIsaac, Goel, To, & Low, 2000

• Fine, Nizet, & Mandl, in 2012• 3 years or older

McIsaac Score, Modified Centor Score

• Group A Streptococcal (GAS) from viral pharyngitis

• Sensitivity for identifying GAS infection

• 83.1% of the time compared to 69.4% usual care

• Validated:• Centor, Witherspoon, Dalton,

Brody, & Link, 1981• Fine, Nizet, & Mandl, in 2012

• 15 years or older

Centor Criteria

Criteria Score

Temperature above 100.4 1

Absence of cough

(as cough is more likely to be associated

with a viral infection)

1

Swollen or tender anterior cervical

lymph nodes

1

Tonsillar swelling or exudates 1

(Centor Criteria adapted for Presentation by M. Denning-Maldonado, 2018)

Literature Review

Hildreth, A. F., Takhar, S., Clark, M. A., & Hatten, B. (2015). Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department. Emergency Medicine Practice, 17(9), 1-16.

Theoretical Framework

Lewin’s Change Theory

Kaminski, J. (Winter, 2011). Theory applied to informatics – Lewin’s Change Theory. CJNI: Canadian Journal of Nursing Informatics, 6 (1), Editorial. http://cjni.net/journal/?p=1210

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FADE MODELFocus

• Clinical Reflective Journal

Analyze• Literature

Review

Develop• Capstone Project

designed

Execute/ Evaluate

• Capstone Project implemented

• Evaluate data

(FADE Model adapted for Presentation by M. Denning-Maldonado, 2018)

• Implement diagnostic tool

• No antibiotic given for Centor Score of 0 or 1

• Symptomatic treatment only

• Quality care measures improved http://www.vacms.org/page-18086

Outcomes• 21 participants

included

• 20 symptoms resolved (95%)

• 2 returned for re-evaluation

• 44 participants total

• 23 excluded

Bacterial on return

visit, 1, 5%

Viral Symptoms Resolved, 20, 95%

• Evidence-based practice guiding decisions

• Translating research into clinical practice

• Empower patients with education

Implications for Nursing Practice

http://www.nursesmovingforward.com/innovation/time-innovation-now-says-mark-cuban/

Provider Solutions

• Focus on Symptoms

• Delayed Prescription

• Office materials

• Keep calm and use time wisely

(Martinez, et al., 2018) https://www.fdiworlddental.org/news/20171117/fdi-continues-to-represent-the-profession-at-global-event-on-antimicrobial-resistance

Conclusion

• Transform Care

• Patients wants

• Provider approach

• Best practice

• Quality patient care http://www.ebnhealth.com/index.php/how-we-can-help/best-practice-guidelines-and-drug-information

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ReferencesAustin, T., & Jarvis, C. (1998). How to save time, money, and a precious resource via CQI.

MLO: Medical Laboratory Observer, 30(1), 50.Centers for Disease Control and Prevention. Antibiotic resistance threats in the United

States, 2013. http://www.cdc.gov/drugresistance/threat -report-2013/. Accessed March 5, 2018.

Centor, R. M., Witherspoon, J. M., Dalton, H. P., Brody, C. E., & Link, K. (1981). The diagnosis of strep throat in adults in the emergency room. Medical Decision Making: An International Journal Of The Society For Medical Decision Making, 1(3), 239-246.

Fiore, D. C., Fettic, L. P., Wright, S. D., & Ferrara, B. R. (2018). Antibiotic Overprescribing Still a Major Concern: Antibiotic overuse has far-reaching effects on patients' general

health, as well as possible connections to HIV, diabetes, and obesity. Clinician Reviews (pp. 22-32). Frontline Medical Communications.Fine, A. M., Nizet, V., & Mandl, K. D. (2012). Large-scale validation of the Centor and

McIsaac scores to predict group A streptococcal pharyngitis. Archives Of Internal Medicine, 172(11), 847-852.Hildreth, A. F., Takhar, S., Clark, M. A., & Hatten, B. (2015). Evidence-Based Evaluation And

Management Of Patients With Pharyngitis In The Emergency Department. Emergency Medicine Practice, 17(9), 1-16.

Huovinen, P., Lahtonen, R., Ziegler, T., et al. (1989) Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. Ann Intern Med, 110(8), 612-616.

Lewin, K. (1951). Field Theory in Social Science: Selected Theoretical Papers. New York: Harper and Brothers.

Linder, J.A. (2008). Editorial commentary: antibiotics for treatment of acute respiratory tract infections: decreasing benefit, increasing risk, and the irrelevance of antimicrobial resistance. Clin Infect Dis. 47(6):744-746.

Martinez, K. A., Rood, M., Jhangiani N., Boissy, A., & Rothberg, M. B., (2018). Antibiotic prescribing for respiratory tract infections and encounter length: An observational study of telemedicine. Annals of Internal Medicine, 17(4), 257-277.

McIsaac, W.J., Goel, V., To, T., & Low, D.E. (2000). The validity of a sore throat score in family practice. CMAJ, 163(7), 811-815.

McIsaac, W.J., White, D., Tannenbaum, D., & Low, D.E. (1998). A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ, 158(1), 75-83.

Niska, R., Bhuiya, F., & Xu, J. (2010). National hospital ambulatory medical care survey: 2007 emergency department summary. National Health Statistics Reports (26), 1-31.

Nursing-theory.org. (2016). Kurt Lewin - Nursing Theory. Retrieved from http://www.nursingtheory.org/nursing-theorists/Kurt-Lewin.php

Pelucchi, C., Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., & Verheij, T. (2012). Guideline for the management of acute sore throat. Clinical Microbiology And Infection: The Official Publication Of The European Society Of Clinical Microbiology And Infectious Diseases, 18(1),11-28.

Schumock, G. T., Li, E. C., Suda, K. J., Wiest, M. D., Stubbings, J., Matusiak, L. M., & VERMEULEN, L.C. (2015). National trends in prescription drug expenditures and projections for 2015. American Journal Of Health-System Pharmacy, 72(9), 717-736.

Snow, V., Mottur-Pilson, C., Cooper, R. J., & Hoffman, J. R. (2001). Principles of appropriate antibiotic use for acute pharyngitis in adults. Annals Of Internal Medicine, 134(6), 506-508.

Suda, K. J., Hicks, L. A., Roberts, R. M., Hunkler, R. J., Matusiak, L. M., & Schumock, G. T., (2010). Antibiotic Expenditures by Medication, Class, and Healthcare Setting in the United States, 2010–2015, Clinical Infectious Diseases, 66(2), 185–190.

World Health Organization (WHO). (2014). Antimicrobial Resistance: Global Report on Surveillance. Retrieved from http://apps.who.int/iris/bitstream/10665/112647/1/WHO_HSE_PED_AIP_2014.2_eng.pd

Questions?