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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?