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## Complete Summary

#### GUIDELINE TITLE

Acute pharyngitis in children.

#### BIBLIOGRAPHIC SOURCE(S)

Michigan Quality Improvement Consortium. Acute pharyngitis in children.
Southfield (MI): Michigan Quality Improvement Consortium; 2007 Jan. 1 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement
Consortium. Acute pharyngitis in children. Southfield (MI): Michigan
Quality Improvement Consortium; 2004 Apr. 1 p

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute pharyngitis, including group A beta hemolytic Streptococcus
(GABHS) infection

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Otolaryngology\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Health Plans\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To achieve significant, measurable improvements in the assessment,
    diagnosis, and treatment of acute pharyngitis through the
    development and implementation of common evidence-based clinical
    practice guidelines

-   To design concise guidelines that are focused on key management
    components of acute pharyngitis to improve outcomes

#### TARGET POPULATION

High-risk and not high-risk children and adolescents 2 to 18 years of
age

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment/Diagnosis**

1.  Assessment of past history of rheumatic fever or household contact
    with a history of rheumatic fever

2.  Assessment of the likelihood of strep pharyngitis

3.  Throat culture (TC) or Rapid Screen test

**Management/Treatment**

1.  Throat culture or Rapid Screen negative: symptomatic treatment,
    avoid antibiotics

2.  Strep pharyngitis:

    -   Penicillin VK

    -   Amoxicillin

    -   Benzathine penicillin G

    -   Erythromycin ethyl succinate if penicillin allergic

    -   Alternative treatment: cephalexin

3.  Re-evaluation and referral to otolaryngologist, if necessary

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Michigan Quality Improvement Consortium (MQIC) project leader
conducts a search of current literature in support of the guideline
topic. Computer database searches are used to identify published studies
and existing protocols and/or clinical practice guidelines on the
selected topic. A database such as MEDLINE and two to three other
databases are used.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence for the Most Significant Recommendations**

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational studies

D.  Opinion of expert panel

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Using the health plan guideline summaries and information obtained from
the literature search, the Michigan Quality Improvement Consortium
(MQIC) director and/or project leader prepare a draft guideline for
review by the MQIC Medical Directors.

The draft guideline and health plan guideline summaries are distributed
to the MQIC Medical Directors for review and discussion at their next
committee meeting.

The review/revision cycle may be conducted over several meetings before
consensus is reached. Each version of the draft guideline is distributed
to the MQIC Medical Directors, Measurement, and Implementation Committee
members for review and comments. All feedback received is distributed to
the entire membership.

Once the MQIC Medical Directors achieve consensus on the draft
guideline, it is considered approved for external distribution to
practitioners with review and comments requested.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Once the Michigan Quality Improvement Consortium (MQIC) Medical
Directors achieve consensus on the draft guideline, it is considered
approved for external distribution to practitioners with review and
comments requested.

The MQIC director also forwards the approved guideline draft to
presidents of the appropriate state medical specialty societies for
their input. All feedback received from external reviews is presented
for discussion at the next MQIC Medical Directors Committee meeting. In
addition, physicians are invited to attend the committee meeting to
present their comments.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The level of evidence grades (A-D) are provided for the most significant
recommendations and are defined at the end of the \"Major
Recommendations\" field.

**Assessment**

Assess past history of rheumatic fever (especially carditis or valvular
disease) or household contact with a history of rheumatic fever to
identify high-risk patients.

Assess the likelihood of strep pharyngitis using the following items:

-   Sudden onset

-   Sore throat

-   Fever

-   Patchy discrete exudate

-   Headache

-   Nausea, vomiting, and abdominal pain

-   Inflammation of pharynx and tonsils

-   Tender, enlarged anterior cervical nodes

-   Patient aged 5--15 years

-   Presentation in winter or early spring

-   History of exposure

**Diagnosis**

**Not High-Risk Patients**

*Probability of group A beta hemolytic streptococci (GABHS)*: Low\
*Testing*: None\
*Treatment*: Symptomatic treatment only. **Avoid antibiotics**.

*Probability of GABHS*: Intermediate or High\
*Testing*: Throat Culture (TC) **OR** Rapid Screen\
*Treatment*: If TC is positive, use antibiotics.\
If TC is negative, use symptomatic treatment only. **Avoid
antibiotics**.\
If treatment is started and culture result is negative, stop
antibiotics.\
If Rapid Screen is positive, use antibiotics.\
If Rapid Screen is negative, culture^1^ and only use antibiotics if
throat culture is positive.

^1^Culture optional for age 16 and over

**High Risk Patients** (history of rheumatic fever or household contact)

Start antibiotics immediately. If throat culture is obtained and is
negative, stop antibiotics.

**Treatment**

**Preferred Treatment for Strep Pharyngitis**

1.  Penicillin VK: 250--500 mg twice or three times daily (bid-tid) x 10
    days

2.  Amoxicillin: 20--40 mg/kg/day divided tid x 10 days **\[A\]**

3.  Benzathine penicillin G intramuscularly (IM) x 1: 600,000 units for
    weight \< 60 lbs; 1.2 million units for weight \> 60 lbs

4.  If allergic to penicillin: erythromycin ethyl succinate: 40
    mg/kg/day two-four times daily (bid-qid) (max 1 g/day) x 10 days

5.  With oral antibiotics, a full 10 day course is required

**Alternative Treatment for Strep Pharyngitis**

6.  Cephalexin 15 to 50 mg/kg/day divided bid or tid x 10 days

**Re-Evaluate/Referral**

1.  If failure to respond clinically after 48 hours of treatment, rule
    out peritonsillar or retropharyngeal abscess. If present, prompt
    otolaryngology (ENT) evaluation is recommended.

2.  Assess the potential for a compliance problem.

**Definitions**:

**Levels of Evidence for the Most Significant Recommendation**

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational studies

D.  Opinion of expert panel

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is provided for the most significant
recommendations (see \"Major Recommendations\" field).

This guideline is based on several sources including, the *ICSI Acute
Pharyngitis Guideline*, Institute for Clinical Systems Improvement, 2005
([www.icsi.org](http://www.icsi.org/)).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Through a collaborative approach to developing and implementing common
clinical practice guidelines and performance measures for assessment,
diagnosis, and treatment of acute pharyngitis in children, Michigan
health plans will achieve consistent delivery of evidence-based services
and better health outcomes. This approach also will augment the practice
environment for physicians by reducing the administrative burdens
imposed by compliance with diverse health plan guidelines and associated
requirements.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline lists core management steps. Individual patient
considerations and advances in medical science may supersede or modify
these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

When consensus is reached on a final version of the guideline, a
statewide mailing of the approved guideline is completed. The guideline
is distributed to physicians in the following medical specialties:

-   Family Practice

-   General Practice

-   Internal Medicine

-   Other Specialists for which the guideline is applicable (e.g.,
    endocrinologists, allergists, pediatricians, cardiologists)

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Michigan Quality Improvement Consortium. Acute pharyngitis in children.
Southfield (MI): Michigan Quality Improvement Consortium; 2007 Jan. 1 p.

#### ADAPTATION

This guideline is based on several sources including, the *ICSI Acute
Pharyngitis Guideline*, Institute for Clinical Systems Improvement, 2005
([www.icsi.org](http://www.icsi.org/)).

#### DATE RELEASED

2004 Apr (revised 2007 Jan)

#### GUIDELINE DEVELOPER(S)

Michigan Quality Improvement Consortium - Professional Association

#### SOURCE(S) OF FUNDING

Michigan Quality Improvement Consortium

#### GUIDELINE COMMITTEE

Michigan Quality Improvement Consortium Medical Director\'s Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Physician representatives from participating Michigan Quality
Improvement Consortium health plans, Michigan State Medical Society,
Michigan Osteopathic Association, Michigan Association of Health Plans,
Michigan Department of Community Health, and Michigan Peer Review
Organization

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement
Consortium. Acute pharyngitis in children. Southfield (MI): Michigan
Quality Improvement Consortium; 2004 Apr. 1 p

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Michigan Quality Improvement Consortium Web
site](http://www.mqic.org/pdf/REVISED MQIC 2007 Acute Pharyngitis in Children Guideline.pdf).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on November 28, 2005. The updated
information was verified by the guideline developer on December 19,
2005. This NGC summary was updated by ECRI on October 16, 2006. The
updated information was verified by the guideline developer on November
3, 2006. This NGC summary was updated by ECRI Institute on July 11,
2007. The updated information was verified by the guideline developer on
July 16, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
reproduced with the citation developed by the Michigan Quality
Improvement Consortium.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
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Guidelines represented on the NGC Web site are submitted by guideline
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<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008