Diagnostic Accuracy of Acute Streptococcal Pharyngo-tonsillitis using the Centor Score Among Adults in the Malaysian Local Primary Care Setting to Improve Prescribing Practices (Aneesa Abdul Rashid)

Overview Research idea in Malaysia Funded by the Ministry of Education Why & briefly literature review What Proposed methodology Suggestions

Background Upper Respiratory Tract Infection (URTI) is a common presentation in primary care1,2.Pharyngo-tonsillitis (PT):1-2% of all healthcare visits3 Group A ß-Haemolytic Streptococcus (GABHS) can cause significant morbidity ; needs early diagnosis and treatment3,4 Research has shown prescribing habits among primary care clinicians in the treatment of URTI are improper and injudicious (including Malaysia)6,18,19,20,21 **First contact primary care is not usually provided by a family physician; medical officer Leads to significant health and economic implications due to antibiotic resistance7,8 GABHS resistance to erythromycin and ampicillin in Malaysia has been steadily increasing23 1. Del Mar et al 2002, 2. Cheong et al 2004, 3. Malaysian Society of Otorhinolaryngologists Head & Neck Surgeons. Consensus Guideline on Upper Respiratory Tract Infections 2009, 4. Teng et al, 2014, 6. Ng et al., 2012, 7. Gandraet al, 2014 , 8. Ng et al., 2012, 18. Wang et al 1999, 19 Ng et al 2012, 20.Teng et al 2012, 21. Almeman et al 2014, 23. IMR-MOH 2014

Literature Review: Diagnosis In Patients With Sore Throat Common pathogens:viruses & Bacteria: GABHS Gold standard for diagnosis of GAHBS : throat culture or the Rapid Antigen Detecting Test (RADT) 9 Not widely available and of high cost3 In Malaysia its not available in public sector (where the vast majority of patients are) URTI: infections of the nasal cavity, the pharynx, and tonsils PT: infection of the pharynx including the tonsils and the adenoids3 3. Malaysian Society of Otorhinolaryngologists Head & Neck Surgeons. Consensus Guideline on Upper Respiratory Tract Infections 2009, . 9.Meland et al 1993

Literature Review: Tools for clinical scoring There are several clinical scoring tools available10,11,12,13,14 The Centor score is a well calibrated clinical prediction rule for estimating the probability of adult GABHS pharyngitis 16 Research shows it can enhance appropriate prescribing of antibiotics in clinical practice16 The modified centor score was adapted for the use of both adults and children25 Both the modified Centor and Centor score is widely accepted and validated scoring tools 15 Its sensitivity and specificity is 85% and 92% respectively 17 10. Komaroff et al 1986, 11. Walsh et al 1975, 12.Beese et al 1977, 13. Clancy et al 1988, 14.Centor et al 1981 15. Fine et al 2012 16. Aalbers et al 2011, 17.McIsaac et al 2000, 25. Mc isaac et al 2004

Literature Review: Antibiotic Use Appropriateness of antibiotic use in relation to the Centor Score One study showed prescription of antibiotic using the Centor score method vs just physician observation reduced antibiotic use by 48%24 Another study showed the percentage of unnecessary antibiotics was <20% if they treated all adults with a Centor score with 3 or 4 25 Hence, where the throat swab is not possible, the Centor score seems a good option to reduce improper antibiotic use Studies quote cost and implications of antibiotic resistance on healthcare costs are substantial 22 However the best method was by treating a positive Rapid Antigen Detecting Test (RADT) which yieled only a 5% unnecessary antibiotics25 24. Mc Isaac et all 1998, 25. Mc isaac et all 2004

Research Questions What is the proportion of bacterial (GABHS) and viral pharyngo-tonsilitis in patients presenting to primary healthcare clinics in the local primary care setting of Sepang District? How sensitive and accurate is the Centor score in diagnosing streptococcal pharyngo-tonsilitis in the local primary care setting of Sepang District? How does the Centor score compare to throat swab results in terms of antibiotics prescribing in acute pharyngitis in the local primary care setting of Sepang district

Proposed Methodology METHODOLOGY COMMENTS STUDY DESIGN Cross-sectional STUDY POPULATION Patients who attend and register with the three primary care clinics who present with symptoms of sore throat SAMPLING FRAME A list of patients who attend the three primary care clinics with sore throat during the period of data collection DATA COLLECTION PERIOD between July 2016 – April 2017 SAMPLING UNIT A patient who presents with sore throat SAMPLING METHOD systematic random sampling will be used in recruitment of patients at all the 3 primary care centres SAMPLE SIZE (n=27%2, prevalence of URTI in Primary Care, Malaysia) Sample size, n = (1.96) ² 0.27 (1- 0.27) 0.05² = 303 + (10%) = 330

Proposed Methodology INCLUSION CRITERIA EXCLUSION CRITERIA All adults aged 18 years and older . Presence of sore throat less than 2 weeks duration Use of antibiotics within the past 2 weeks
 Immuno-deficient patients
 Very ill patients requiring acute emergency treatment Pregnant women Acute psychiatric illness

Expected outcomes Publication in a Peer Review Journal: local data on the proportion of both viral and bacterial causes of pharyngo-tonsillitis. local data on proportion of inappropriate antibiotic prescription with a validated scoring criteria and laboratory evidence local data on resistance rates of GABHS causing pharyngo-tonsillitis to prevent antibiotic resistance an effective tool to help local clinicians make a choice on proper antibiotic prescription Influenced guidelines to incoporate the tool

Questions/Discussions 1. What are the improvements for research methodology- random sampling, sampling issues 2. What is the best approach for ensuring the clinicians use clinical scoring tool?

Team Members Aneesa Abdul Rashid Sazlina Shariff, Hani Syahida Salim, Nurainul Hana Shamsuddin, Marliza Mawardi, Siti Zulaikha Zakariah Department of Family Medicine & Department of Pathology, University Putra Malaysia