PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A β-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat

Paul Little; Michael Moore; F D R Hobbs; David Mant; Cliodna McNulty; Ian Williamson; Edith Cheng; Beth Stuart; Joanne Kelly; Jane Barnett; Mark Mullee; PRISM investigators

doi:10.1136/bmjopen-2013-003943

PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A β-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat

BMJ Open. 2013 Oct 25;3(10):e003943. doi: 10.1136/bmjopen-2013-003943.

Authors

Paul Little¹, Michael Moore, F D R Hobbs, David Mant, Cliodna McNulty, Ian Williamson, Edith Cheng, Beth Stuart, Joanne Kelly, Jane Barnett, Mark Mullee; PRISM investigators

Collaborators

PRISM investigators:
James Raftery, David Turner, Rafael Pinedo-Villanueva, Karen Middleton, Gerry Leydon, Richard Hobbs, Richard McManus, Paul Glasziou, Sue Smith, Diane Coulson, Peter Hawtin

Affiliation

¹ Primary Care and Population Science Unit, University of Southampton, Southampton, UK.

Abstract

Objective: To assess the association between features of acute sore throat and the growth of streptococci from culturing a throat swab.

Design: Diagnostic cohort.

Setting: UK general practices.

Participants: Patients aged 5 or over presenting with an acute sore throat. Patients were recruited for a second cohort (cohort 2, n=517) consecutively after the first (cohort 1, n=606) from similar practices.

Main outcome: Predictors of the presence of Lancefield A/C/G streptococci.

Results: The clinical score developed from cohort 1 had poor discrimination in cohort 2 (bootstrapped estimate of area under the receiver operator characteristic (ROC) curve (0.65), due to the poor validity of the individual items in the second data set. Variables significant in multivariate analysis in both cohorts were rapid attendance (prior duration 3 days or less; multivariate adjusted OR 1.92 cohort, 1.67 cohort 2); fever in the last 24 h (1.69, 2.40); and doctor assessment of severity (severely inflamed pharynx/tonsils (2.28, 2.29)). The absence of coryza or cough and purulent tonsils were significant in univariate analysis in both cohorts and in multivariate analysis in one cohort. A five-item score based on Fever, Purulence, Attend rapidly (3 days or less), severely Inflamed tonsils and No cough or coryza (FeverPAIN) had moderate predictive value (bootstrapped area under the ROC curve 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection (38% in cohort 1, 36% in cohort 2 scored ≤1, associated with a streptococcal percentage of 13% and 18%, respectively). A Centor score of ≤1 identified 23% and 26% of participants with streptococcal percentages of 10% and 28%, respectively.

Conclusions: Items widely used to help identify streptococcal sore throat may not be the most consistent. A modified clinical scoring system (FeverPAIN) which requires further validation may be clinically helpful in identifying individuals who are unlikely to have major pathogenic streptococci.

Keywords: Primary Care.