This is the first objective study to assess antibiotics prescribing and physicians’ adherence to clinical guidelines regarding the management of pharyngitis in paediatric population in Palestine. The results revealed that throat swabs are not used routinely in the studied setting which led to expected overprescribing of antibiotics. Moreover, inappropriate antibiotic selection was observed as well. As indicated by the results, around three-quarters of the cases had a Modified Centor score of ≥ 2. According to clinical guidelines, a Modified Centor score of ≥2 necessitates testing for GABHS pharyngitis using throat swab or RADT, as the likelihood for GABHS pharyngitis in patients having a Modified Centor score of 2 is estimated to be 20.5% and increases as the score increases[14]. Antibiotic therapy should be started once GABHS pharyngitis is documented by RADT or throat culture. However, only 8 throat cultures were obtained, yet 160 patients (55%) received antibiotics empirically, without any confirmatory test for the presence of bacterial pharyngitis. Throat swabs are an essential part of pharyngitis management, and their use is encouraged in various clinical guidelines to properly guide therapy and decrease unnecessary antibiotics use [15].
Our findings revealed that 74.8% of patients had a score of ≥ 2, and more than half of them received antibiotics without having any confirmatory tests for GABHS pharyngitis (throat culture was ordered only for 8 of them). This is an alarming finding and would lead to significant overuse of antibiotics. As previous studies showed that only 25% of patients with a Centor score of ≥ 3 had a documented positive throat culture for GABHS pharyngitis [16]. On the other hand, even patients having a score < 2, half of them received antibiotics, while no throat swabs were ordered for these patients. However, it was found that the higher the Centor score is the higher the chance of antibiotic prescribing (r = 0.154, p = 0.009). This indicates that the more signs and symptoms the child experience, the more likely physicians will attribute it to bacterial causes. This emphasizes the vital role of throat cultures, as a certain diagnosis can’t be made relying only on clinical features. Moreover, in the absence of a positive throat culture or RADT, overestimation of bacterial pharyngitis and the associated antibiotic use remain a true concern.
In this study fever was found to be the most common complaint occurring in one third of the study sample and was significantly associated with antibiotics prescribing. This finding is in agreement with other studies where fever was reported to be the most common clinical feature in confirmed bacterial cases [16]. However, fever is also seen in viral pharyngitis and decisions made solely based on the presence of fever might lead to antibiotics overuse.
In pharyngitis, similar to other infections, there might be certain alarming information demanding and justifying the use of empirical antibiotics before obtaining swab results. These include limited conditions where a patient has a high suspicion of GABHS pharyngitis; i.e. having a diagnosis of scarlet fever, a symptomatic child having a household member with documented GABHS infection or in cases where the patient (or a family member) has a history of ARF [3].
However, if none of the mentioned criteria is present, diagnosis should always be confirmed using throat culture or RADT prior to antibiotic initiation [3]. This is a safe practice even when MCS is >2 (i.e GABHS is suspected) since starting antibiotics in bacterial pharyngitis within 9 days of symptom onset can still prevent the development of complications (mainly rheumatic fever) [3, 17].
Regarding antibiotic selection, there was an obvious inappropriate antibiotic selection, similar to previous findings involving paediatric patients [18]. In a study that was conducted in Canada, for example, antibiotics were prescribed inappropriately in 85% of cases in preschool children having pharyngitis [8]. Another study from the United states showed that over a quarter of children received antibiotics for pharyngitis, although they weren’t indicated according to treatment guidelines[7]. This indicates that antibiotic overprescribing is a global issue facing the healthcare sector, not only in our studied setting. Oral penicillin V or amoxicillin are recommended in treating GABHS pharyngitis and should be selected as first line agents for patients without penicillin allergy. These agents have a narrow spectrum of activity, few side effects and are of reasonable cost [19]. Macrolides and cephalosporins can be used as alternatives for type I and II penicillin allergies, respectively [3]. However, as shown by Table 4, azithromycin was prescribed for 66 patients (41%) whereas only 2 patients had a documented penicillin allergy. These findings are similar to other studies’ findings where macrolides use in pharyngitis was reported to be substantially increasing against the recommendations of treatment guidelines [18]. Physicians are advised to adhere to clinical guidelines regarding antibiotic selection as there is no evidence that macrolides are clinically superior to penicillin in the absence of penicillin allergy [20].
Pharyngitis cases can be seen anytime throughout the year, but peak seasons depend on the causative agent, and it is generally during winter[3, 21, 22]. This matches our results (Fig. 1), as the highest incidence was in December. However, pharyngitis cases due to viral causes, are usually seen in summer [2, 21]. This could explain the gradual increase of visits from June to September as shown in Chart 1. However, when it comes to antibiotics prescribing, the rate of antibiotic prescribing was not found to be altered by the time of the year at which a case was seen (p value: 0.520). This could indicate that little attention is being payed to viral pharyngitis as a possible and common cause for pharyngitis especially in summer season. Another interesting finding is that antibiotic prescribing rate was significantly higher in elder children than younger children which might be out of fear of developing serious complications such as ARF. Overall, the results of this study highlight the need for enforcing committing to guidelines in the management of pharyngitis.