Jääskeläinen et al. BMC Pediatrics(2024) 24:503
https://doi.org/10.1186/s12887-024-04982-x

BMC Pediatrics

RESEARCH

Open Access

The impact of national guidelines on the
diagnostics of sore throat in children
Johanna Jääskeläinen1*, Marjo Renko1,2 and Ilari Kuitunen1,3
Abstract
Background The Finnish treatment guidelines for sore throat were updated in June 2020. The aim of this study
was to determine how the publication of these guidelines affected the treatment of pediatric patients, particularly
through the use of the Centor criteria, C-reactive protein tests, and microbiological testing in the diagnosis of Group A
β-hemolytic streptococci tonsillitis.
Methods We conducted a retrospective single-center before-and-after cohort study in Finland from 2019 to 2022.
We included all patients who visited the pediatric emergency department and were diagnosed with tonsillitis orpharyngitis.
Results We included 246 patients who were admitted before the guidelines were updated and 219 patients after.
Only two patients in the after group had a Centor score reported in their patient records. Rapid antigen tests wereadministered to 231 patients (93.9%) before the update and 202 patients (92.2%) after (proportion difference of 1.7%,
CI -3.0–6.6%). C-reactive protein was taken from 193 patients (78.5%) before the update and 189 patients (86.3%) after(proportion difference of 7.8%, CI 0.1–14.7%).
Conclusions Centor scores were not used as recommended in the guidelines and did not impact the use of
microbiological or C-reactive protein testing. More education and examining the preconceptions of health carepersonnel is required to implement the updated treatment guidelines in clinical practice.
Keywords Acute pharyngitis, Group A β-haemolytic streptococci (GAS), Centor score, Treatment guideline

Introduction
Acute pharyngitis is a common reason for seeking medical advice. The majority of pharyngitis cases are causedby viruses, and approximately 24–37% of children’s pharyngitis is caused by Group A β-haemolytic streptococci(GAS) [1–3]. In high-income countries, rheumatic fever
and rheumatic heart disease are rare complications of*Correspondence:
Johanna Jääskeläinen
johajaa@student.uef.fi
1Institute of Clinical Medicine, Department of Pediatrics, University ofEastern Finland, Kuopio, Finland2
Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland3
Department of Pediatrics, Mikkeli Central Hospital, Mikkeli, Finland

GAS infections, but they still impose a large disease burden in low-income countries [4]. GAS pharyngitis canlead to suppurative complications, such as peritonsillar
and retropharyngeal abscess, as well as toxin-mediatedcomplications, scarlet fever, and streptococcal toxic
shock syndrome. These complications are rare in highincome countries, and GAS is usually self-limited; therefore, antibiotic treatment should not be started to only
prevent suppurative complications or relieve symptoms
in patients with mild symptoms [3].
The Finnish treatment guidelines for sore throat were
updated in June 2020, and the Centor score was presented as a diagnostic tool for GAS pharyngitis. According to the Centor criteria, one point is given for each of© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
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the following symptoms and clinical findings: absence of
cough, tender and swollen submandibular lymph nodes,
tonsillar exudate or swollen tonsils, and fever ≥ 38˚C. In
the guideline update Centor score is recommended touse to direct antibiotic treatment to patients with more
severe symptoms and higher likelihood of GAS. Patientswith mild symptoms and Centor score (0–2) are recommended to be treated symptomatically and patients withsevere symptoms (3–4) are recommended to be treatedbased on microbiological test results. A new guideline formicrobiological testing of GAS was also provided. The
new guidelines recommend using a rapid antigen detection test in patients with a Centor score of 3 or more.
Throat culture should only be used in patients with prolonged symptoms or in epidemic situations. The guidelines also recommend against using C-reactive protein(CRP) tests in the diagnosis of pharyngitis, as they are
ineffective at distinguishing viral from bacterial pathogens [5, 6].
The aim of this study was to determine how the publication of the updated Finnish Current Care Guidelines
affected treatment for pediatric patients, particularly theuse of the Centor criteria, CRP tests, and microbiologicaltesting in the diagnosis of GAS tonsillitis.

Methods
We conducted a retrospective single-center before-andafter cohort study. Participants were recruited from the
Mikkeli Central Hospital pediatric emergency department. This pediatric emergency department is a 24/7
primary and secondary level emergency care unit thatprovides on-call general practitioner, pediatrician, andENT specialist consultation services.
We included all pediatric patients (0–15 years) with an
ICD-10 diagnostic code of J02* (pharyngitis) or J03* (tonsillitis) who attended the emergency department between
July 2019 and June 2022. The study periods were prior
to the publication of the latest national guidelines (July2019 to June 2020) and after (July 2020 to June 2022). We
Table 1 Baseline characteristics of children with pharyngitis
before and after publication of the updated guidelines

Age in years, mean (SD)
GenderFemaleMale
No diagnosed long-term illnesses
Asthma, atopic disease
Rheumatoid arthritis, inflammatory bowel
disease, cancer, other immunodeficiency
Type 1 diabetes
Other
Missing, not reported

Before(n = 246)
8.1 (± 4.3)
129 (47%)144 (53%)207 (84%)
14 (5.7%)
2 (0.8%)After(n = 219)
10 (± 4.1)
135 (55%)
122 (49%)
172 (79%)
15 (6.8%)
1 (0.5%)0 (0.0%)23 (9.3%)
0 (0.0%)1 (0.5%)29 (13%)5 (2.3%)

calculated that 200 patients before and 200 patients after
the update to the Finnish Current Care Guidelines would
be a sufficient sample to represent changes in the diagnosis and treatment of pharyngitis. Since the COVID-19
pandemic reduced the circulation of respiratory pathogens in children in 2020 and 2021, we collected data for
two years after the update to achieve the desired numberof patients [7, 8]. Only primary visits were included.
We extracted the following information for every
patient and visit: date, age, sex, previously diagnosed
long-term illnesses, fever (measured or anamnestic),
complaint of sore throat, complaint of cough, tonsillar status, swollen or sore cervical lymph nodes, Centor
score, and rapid antigen, throat culture, and CRP test
results (if taken). We calculated Centor scores based on
the symptoms reported in the patient records and compared them and the number of rapid antigen tests takenin the before and after groups.
Our main outcomes were the use of Centor scores andlaboratory tests (i.e., CRP and microbiological testing for
GAS) in pediatric patients with pharyngitis or tonsillitis.
Statistics

We determined that it would be clinically significant if
the publication of the Current Care Guidelines increased
the use of Centor criteria in assessing the need for microbiological samples from 10 to 25%. We calculated thatwith a type I error of 5% and a type II error of 10%, wewould need 147 patients before and 147 patients after
the publication of the guideline to demonstrate this 15%
absolute difference. Since complete information is notavailable in all patients’ medical records, we included 200
patients before and 200 patients after the publication of
the new guidelines.
We compared the rates before and after the guideline
publication by calculating their difference in proportions
and the 95% confidence interval for it.

Results
All 246 consecutive patients diagnosed with pharyngitis
before the update of the guidelines acted as the before
group, and 219 patients diagnosed with pharyngitis after
the update acted as the after group. The study population
included both primary and secondary care patients fromwhich approximately 95% were primary care patients.
The mean age in the before group was 8.1 years (SD = 4.3)
and 10.0 years (SD = 4.2) in the after group. The gender
distribution was similar in the before and after groups,
47% and 55% of the patients were females in the before
and after groups respectively. The majority of the children included in the study did not have any long-term illnesses (Table 1).
Only two patients after the update had Centor scorescalculated and reported in their patient records.

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Reported symptoms were similar in the before and theafter groups, as well as the amount of incomplete reporting of the symptoms needed to calculate the Centor
score. Absence of cough was more likely to be reported in
the after group (Table 2).
No significant difference was found between the before
and after groups when cases were pooled into groups
based on reported symptoms determining the Centor
score (Table 3). As shown in Table 3, the new guidelines were not followed when taking rapid antigen tests.
Rapid antigen tests were taken from 231 patients (94%)
in the before group and 202 patients (92%) in the after
group (proportion difference of 1.7%, CI -3.0–6.6%). The
use of CRP tests increased after the update. CRP tests
were administered to 193 patients (79%) in the before
group and 189 patients (86%) in the after group (proportion difference of 7.8% CI 0.1–14.7%). In the before
group 4 patients and in the after group 3 patients were
hospitalized.

Table 2 Number of children with symptoms determining centor-score in before and after groups

Discussion
In this observational study, we found that the use ofCentor scores and the reporting of scores according to
the criteria of the updated treatment guidelines for sorethroat in were not implemented in clinical practice. In
the guidelines, the use of the Centor score was presented
as a tool for practitioners to estimate the likelihood of
GAS pharyngitis and to guide the use of microbiologicaltests. Centor scores were reported in only two patients
after the update. Presence of cough and information on
swollen lymph nodes were most often missing from the
medical reports. We calculated the Centor score for eachcase from the reported symptoms to see if rapid antigen
tests were indicated for patients with Centor scores of≥ 3. As seen in Table 3, rapid antigen tests were administered almost equally in both groups, and no significant
change was seen after the update.
The updated guidelines recommend against using CRP
tests in diagnosing sore throat, as they are ineffective at
distinguishing viral from bacterial pathogens. However,

we did not see any change in the use of CRP tests between
the before and after groups. Overall, the use of CRP tests
was high in this patient series. Although administering
CRP tests has benefits in clinical work—for example, in
reducing antibiotic prescriptions for children with upper
respiratory tract infections—it is not useful for predicting
the presence of GAS [9, 10].
The previous Current Care guideline, published in2013, recommended the use of Mclsaac score for screening of GAS, throat culture as a primary microbiologicaltest and confirming of negative rapid antigen tests with
culture. However, the use of Mclsaac score in Finland
hasn’t been reported and seemingly it hasn’t been incommon use. Our findings align with several previous
studies, for example a study conducted in 2006 in Boston,where general practitioners were nonadherent to guideline strategies for streptococcal testing in adults [11].
A 2018 Australian study also showed that adherence toclinical practice guidelines is limited [12].

Before (n = 246)
Cough
Yes, n (%)
No, n (%)
Not assessed or reported
Fever over 38˚C measured or
anamnestic
Yes, n (%)
No, n (%)
Not assessed or reported
Swollen lymph nodes
Yes, n (%)
No, n (%)
Not assessed or reported
Tonsils
Swollen or exudate, n (%)
Normal/redness, n (%)
Not assessed or reported

56 (23%)39 (16%)151 (61%)After(n = 219)
55 (25%)67 (31%)
97 (44%)136 (55%)
51 (21%)59 (24%)96 (44%)69 (32%)54 (25%)66 (27%)79 (32%)101 (41%)52 (24%)78 (36%)88 (40%)162 (66%)
73 (30%)11 (4.5%)

150
(69%)
57 (26%)
12 (5.5%)

Table 3 Number of children with centor scores calculated based on reported symptoms and rapid antigen tests taken before andafter publication of the updated guideline
Centor score
0

Before (n = 246)n (%)
Test taken n (%)
31 (13)23 (74)After (n = 219)n (%)
28 (13)

Test taken n (%)
25 (89)12
3

80 (33)88 (36)41(17)

75 (94)86 (98)41 (100)

71 (32)70 (32)44 (20)68 (96)62 (89)42 (96)4

6 (2.4)6 (100)5 (2.3)5 (100)

Total

246

231 (94)219

202 (92)

Proportion difference, 95% CI
015%,-5.4–34%
2.0%, 6.3–10%
9.2%, 1.3–19%
4.6%,-4.6–15%0%,-39–44%1.7%,-3.0–6.6%

Jääskeläinen et al. BMC Pediatrics(2024) 24:503

The purpose of the Finnish Current Care Guidelines
is to provide evidence-based treatment guidelines tohelp standardize nationwide treatment protocols. After
publishing the updated guideline, a taskforce released a
media briefing and news article in the Finnish Medical
Library Handbook and on the Duodecim website andsocial media accounts, in addition to announcements
in medical conventions, professional development days,
and specialty societies. Based on the results of this study,
these measures are insufficient to impact the diagnostic protocols of acute pharyngitis. Our results, as well
as reports from other countries, show that the mere
publication of guidelines will not immediately change
previous practices, and thus implementation is necessary [13, 14]. An interview of Swedish GPs showed thatguideline adherence was low especially if recommendation in the guidelines was not compatible with existingnorms and preconceptions of the physicians [15]. Recent
study showed that there is considerable mishandlingof acute pharyngitis in Italian ERs [16]. A Finnish study
that assessed whether published guidelines against theuse of cough medication had an impact on prescriptions
initially found that it did not [17]. However, the study
group reported that after implementing a program withpractical guidance for prescribing, the prescription rates
reduced [18].
Educating general practitioners alone may not be sufficient to change the use of rapid antigen and CRP tests
in patients with sore throat. In general, patients whocome to the emergency department or make acute visits
to primary care facilities first see a nurse, and depending
on regional instructions, nurses administer tests at theirown discretion. Thus, local protocols for testing suchcommon infections are needed to reduce overdiagnosis,
overtreatment, and costs.

Limitations
The main limitation of this study is that it included only
patients from one hospital and health care region in Finland; thus, the results cannot be generalized to the entire
country. The after period starts right after the publicationof update and it is possible that changes can not been
seen right after, although the data collection period spansover two years, some cases would have been recorded
right after the publication of the guideline updates, so it
is possible that changes may not have been seen immediately after. A further limitation is its retrospective design,
as not all information was written in the records, whichmight have influenced the decision to test for GAS. However, the retrospective design enabled us to estimate theimpact of the updated guidelines without implementing
them in practice.

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Conclusion
Centor scores were not used as recommended in the
updated Finnish treatment guidelines for sore throat.
The update did not change the use of microbiologicaltesting in the diagnosis of GAS and these findings are inline with previous studies. Education at several levels of
health care and considering the preconceptions of healthcare personnel even before the creation of new guidelines
is required to better implement them in clinical practice.
Acknowledgements
Not applicable.
Author contributions
J.J. wrote the main manuscript text and prepared the tables. M.R. andI.K contributed to the discussion and methods and have reviewed themanuscript.
Funding
M.D. Jääskeläinen has received research funding from Pediatric researchfoundation.
Data availability
We are unable to provide and share the data in open repositories due toFinnish research law and the law on the secondary use of routinely collected
healthcare data which both prohibit publication or sharing of pseudonymized
data currently. Interested persons may contact the corresponding author for
additional summary level information of our data. In order to gain access tothe full data, an application should be sent to Mikkeli Central Hospital researchcommittee (kirjaamo@etelasavonha.fi) but the current legislation does notallow the transformation of the data outside of the Finnish borders.

Declarations
Ethics approval and consent to participate
The ethical committee evaluation was waived by the Southern Savonia HealthCare District ethical committee. According to the Finnish research legislation
ethical committee evaluation is not needed when routinely collected
healthcare data is analyzed and the participants are not contacted. All
methods were carried out in accordance with relevant guidelines and Finnish
regulations (Law on the secondary use of routinely collected healthcare
data and Law of medical research). We obtained research permission fromthe chief of Mikkeli Central Hospital to gain access to the data. According to
Finnish research law and the law on the secondary use of routinely collected
healthcare data informed consent to participate is not required when
institutional or national register data is analyzed retrospectively. Therefore, theneed for informed consent was waived by the institutional review boards ofthe participating hospital, Mikkeli Central Hospital, of the Southern Savonia
Health Care District.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 27 November 2023 / Accepted: 29 July 2024

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