Total Quality Improvement Assessment Of Strep C β-Hemolytic Streptococci Treatment in a College Population Valerie Kiefer MS, APRN University Of Connecticut

24-Hour Care Fee for Service Departments: ◦Primary Care ◦Walk-In Clinic ◦Women’s Clinic ◦Allergy Clinic ◦Counseling & Mental Health ◦9 Bed In-Patient ◦Laboratory ◦Radiology ◦Pharmacy The University of Connecticut provides primary health care to approximately 20,000 students annually.

What is Group C Streptococcus? Gram positive anaerobe which produce small or large colonies Usually beta hemolytic Share many clinical characteristics with GAS Group C can cause isolated exudative or common source epidemic pharyngitis indistinguishable clinically from GAS Large colony Small colony are not associated with pharyngitis

Why Study Group C Strep? Pharyngitis and Group C Streptococcus common in college health Do You Treat or Test for Group C strep pharyngitis? Unknown if the association of group C (BHS) pharyngitis in college students is related to immunity issues, lifestyle or other factors

Review Of The Literature Studies that have shown strong epidemiologic association between group-C BHS and endemic pharyngitis in college students

Review Of The Literature Turner et al, JAMA 1990 Association of Group C β-Hemolytic Streptococci With Endemic Pharyngitis Among College Students Purpose: NGA BHS could be detected more commonly in the throats of students with symptomatic pharyngitis than among healthy controls of similar age.

Performed throughout 2 school years NGA BHS group, only those from group C were isolated more often/compared with the control group (26% to 11%) Established a strong epidemiologic association between group C BHS and endemic pharyngitis in college students Group C BHS had fever, exudative tonsillitis and anterior cervical adenopathy more frequently than patients who were negative for group C

Turner et al, Journal Of Clinical Microbiology 1997 Epidemiologic Evidence From Lancefield Group C Beta Hemolytic Streptococci As A Cause Of Exudative Pharyngitis In College Students Compared the isolation rates of strains of group C BHS from throat swab cultures of patients with exudative pharyngitis, the common cold, and healthy controls

College health/chart review Isolation of Lancefield group A and C beta-hemolytic streptococci from throat cultures was used as an outcome measurement Lancefield Group C strep associated with purulent exudative pharyngitis in college students.

Broyles et al, Clinical Infectious Disease 2009 Population-Based Study of Invasive Disease Due to β-Hemolytic Streptococci of Groups Other than A and B Different Species of non A, non B – hemolytic streptococci and their clinical significance NABS Comprise multiple distinct species that cause infections. (G,B,H) Manifestations differ, specification may be warranted in clinical settings

Tiemstra et al, Journal American Board Family Medicine 2009 Role of Non Group A Streptococci in Acute Pharyngitis The role of Non Group A strep as pathogens of pharyngitis is controversial. Data is limited and conflicting on whether these bacteria are true pathogens of pharyngitis and whether treatment is indicated in all or just select cases.

Objective: Determine whether in non-GAS identified on culture if the clinical signs and symptoms resemble group A  implicating them as true pathogens or if they resemble culture negative pharyngitis suggesting they are viral in etiology Retrospective case control study Mean age 26 years GAS by RAS or culture Neg. RSA or culture

Headache and fever associated strep infection, no difference between GAS and non GAS Exudates and lymphadenopathy were also associated with both GAS and non GAS compared with viral infection 2 criteria were present, risk any strep infection rose to 55% (27% for non GAS or GAS) 3 or more criteria present, risk increased to 81% (non-GAS 34%, GAS 47%)

Results: Young, adult population with acute pharyngitis, non GAS was as common as GAS Non GAS same clinical features typically associated with GAS Suggests clinicians may want to consider treating patients with proven or presumptive non GAS pharyngitis who fail to respond to symptomatic therapy or who are at increased risk for sequelae Further study needed/antibiotic treatment

Cooper et al, Annals Of Internal Medicine 2001, Principles of Appropriate Antibiotic Use For Acute Pharyngitis In Adults, Position Paper Examines the available evidence regarding the diagnosis and treatment of acute GABHS in adult patients Recommendations made that balance concerns about the potential consequences of untreated GABHS and the goal of decreasing inappropriate antibiotic prescriptions

Group A strep is the causal agent in 10% of adult cases of pharyngitis. Antibiotics are prescribed to 75% of adult patients with acute pharyngitis. Incidence of complications regardless of treatment with antibiotics is low. Antibiotic therapy instituted within 2-3 days of symptom onset hastens symptomatic improvement by 1-2 days in patients/cultures grow GABHS. Antibiotics do not have this effect with a negative culture.

Symptom duration is strongly related to patient satisfaction. Antibiotic treatment benefits only those patients with GABHS. Limit antibiotic prescriptions to patients who are most likely to have GABHS infections.

Rutecki, Top Papers Of The Month, Does This Patient Have Group A Strep Pharyngitis?, Consultant 2012 This paper discussed pharyngitis and the Centor Criteria. Include Centor Criteria in Management/approach to pharyngitis.

Shah, Centor and Jennings, Severe Acute Pharyngitis Caused by Group C Streptococcus, 2006 Case Report Group C Strep. / Approx. 5% prevalence Present Broad Spectrum of Severity Less common cause of acute pharyngitis but has both similar microbiology and presentation to group A. Both cause exudative or epidemic pharyngitis which are indistinguishable clinically.

5 Important Considerations/Neg. RSA/ Worsening Symptoms Mono Acute HIV Group C Peritonsillar Abscess Lemierre’s Syndrome (Fusobacterium necrophorum) Neg. RSA /possibly worsen over the next week

Reasons We Treat Strep Throat Strep A causal agent 10% Reduce Symptoms Prevent the spread of Streptococci Prevent Infectious Complications ◦Tonsillar Abscesses ◦Sinusitis Prevent Rheumatic Fever /2011 incidence of rheumatic fever in the US was 1 per 1 million strep throats Prevent Glomerulonephritis Majority of adults have a self limited illness who do not need antibiotics

Group C Strep- Does not cause some of the complications caused by Group A Uncommon cause of pneumonia Group C Strep sinusitis has been reported Rarely isolated from blood cultures/fewer than 1% of all bacteremia Group C and G Strep meningitis have been reported and are often associated with endocarditis Group C Strep arthritis uncommon/occurs in joints with preexisting rheumatologic abnormalities

Role of Non-Group A Streptococci Conflicting and limited data ◦Guidelines/Standards treat Strep A ◦Controversy regarding management strategy for adult pharyngitis ◦Dr. Centor points out in the article: Pharyngitis Management: Defining the Controversy JGIM (2007) ◦Randomized trial data suggests a symptomatic benefit for treating Group C patients

Infectious Diseases Society of America (IDSA) 2012 Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis Group C Strep common cause of acute pharyngitis among college students and adults Primary reason to identify GCS as the etiologic agent of acute pharyngitis is to initiate antibiotic therapy that may reduce the clinical impact of the illness

Currently, there is no convincing evidence from controlled studies of a clinical response to antibiotic therapy in patients with acute pharyngitis from GCS isolated from the throat CDC recommends not treating GCS.

Community Vs. College Health Rapid Strep A testing (RSA) ◦Fever ◦Exudative Tonsillitis ◦Adenopathy ◦No cough ◦A back up throat culture is not routinely performed ◦Community/Follow up visit

UCONN RSA Back Up Throat Culture Treated by Clinical Presentation RSA Neg.  Strep C  No Improvement  Antibiotic Follow up visit or antibiotic left at clinic for pick up by student Time period of antibiotic treatment could range from 1-5 days post visit

OSOM RSA Ultra Strep A Test 98.2% Sensitive Single Swab Culture Quality of the test depends on the quality of the sample. Negative results can occur from inadequate specimen collection Does not differentiate between carriers and acute infection Used as an adjunct to other information available to the provider

Purpose of Study/Quality Issues Addressed Quality Improvement Assessment To determine if antibiotic use in the treatment of Group C BHS in the college population is appropriate in relationship to community standards/guidelines. ◦College Population DIFFERENT!! To evaluate if the University of Connecticut’s quality of care and guidelines are appropriate in the treatment of Group C BHS

To assess the time frame of treatment or non treatment of Group C BHS. Same day treatment Next day treatment Treatment within 2-5 days of visit To evaluate key indicators in relationship to Group C BHS in the college population. ◦Tonsillitis ◦Mononucleosis Collected data before & after an educational action for clinical staff

Performance Goals Difficult to set/lack of guidelines College Health taken into account 75% adult pharyngitis patients treated with an antibiotic Performance Goals 70% Total Patients Treated with antibiotic 10% Patients Treated with antibiotic day 1 10% Patients Treated with antibiotic day 2- 5 Looked at: Under and over usage of antibiotics Quality of care and outcome issues as well as practice guidelines

Data Description Retrospective Chart Audit January/11 to March/ Diagnosed With Pharyngitis PeopleSoft# Date of Examination Positive for Group C BHS Negative treatment with an antibiotic Treated with an antibiotic/time frame Tonsillitis or Mononucleosis Follow up visit or phone call

Antibiotic Use Before Corrective Action: 119 Positive Group C BHS Patients diagnosed with Strep C January Patients February Patients March Patients Total % Same Day Treatment % Next Day Treatment % Treatment in 2-5 Days % No Treatment % Cases of Tonsillitis %

Follow-Up Done Before Corrective Action Patients diagnosed with Strep C January Patients February Patients March Patients Total % Follow-up Phone Call % Follow-up Visit %

Data Analysis Before Corrective Action: 80% Treated with an antibiotic 44% Same Day 23% Next Day 13% Day % Tonsillitis 6% Mononucleosis 59% Follow-up Phone Call 22% Follow-up Visit

Antibiotics Used Penicillin VK 500 mg TID Zithromax (Z-Pak) Amoxicillin 875 mg BID Augmentin 875 mg-125 mg BID Clindamycin 300 mg TID Biaxin 500 mg BID

IDSA Recommendations PCN 500 MG BID AMOXICILLIN 50 MG/KG QD (MAX = 1000 MG) AZITHROMYCIN 12 MG/KG QD (MAX = 500 MG)

Performance Goals Comparison Goal: 70% Treated Performance: 80% Treated Goal: 10% Treated/Next Day Performance: 24% Treated/Next Day Goal: 10% Treated/Day 2-5 Performance: 13% Treated/Day 2-5

Discussion Community Standards/College Health Standards Laboratory On Site/Depending on the time the student is seen, we will get a throat culture back the next day 2 Day Illness History/Average of 2 days of illness before they come in for an evaluation

Issues Of Concern Antibiotic Offered Too Soon/Patient would have eventually improved and not needed to be treated with an antibiotic 80% Antibiotic Treatment for Strep C was too high in relation to community standards and we were prematurely over prescribing antibiotics Laboratory Turnaround/Prompt turnaround of backup throat cultures contributed to our increased antibiotic usage. If the backup culture was returned 1 day post visit / probability of student still having a sore throat was high which in turn could influence the provider to prescribe an antibiotic

Issues Of Concern Reevaluation Of Symptoms Prescribing antibiotics without consistent reevaluation of patients was not appropriate medical care or follow up and addressed quality of care issues

Corrective Actions Positive Group C BHS results would not be reported until 3 days post visit/Address the quick turnaround time of cultures from our laboratory Laboratory results available if needed/provider call the lab for a result if there was a clinical concern Provider would continue patient education/Issues or concerns call or make an appointment to be seen Comfort Measures/Treatment for Sore Throat

Corrective Actions Clinical Judgment/Same day treatment would not be addressed due to the involvement of the providers judgment regarding antibiotic usage Group C BHS reported to clinician Student with continued symptoms/ follow –up visit/antibiotic would not be left at the clinic or in the pharmacy Original provider or back up clinician

Corrective Actions Implemented January 2012

Re-Measuring Of Data Chart Audit January 2012 to March Charts Audited 773 With Pharyngitis Diagnosed Same Criteria

PeopleSoft # Date Of Examination Positive For Group C BHS Negative Treatment With An Antibiotic Treated With An Antibiotic Time Frame of Treatment Same Day, Next Day, Day 2-5 Tonsillitis or Mononucleosis Diagnosed Follow Up Visit or Phone Call

Data Collection After Corrective Actions: 107 Positive Group C BHS Patients diagnosed with Strep C January Patients February Patients March Patients Total % Same Day Treatment % Next Day Treatment 10233% Treatment in 2-5 Days % No Treatment % Cases Tonsillitis %

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Follow-Up Done After Corrective Action Patients diagnosed with Strep C January Patients February Patients March Patients Total % Follow-up Phone Call % Follow-up Visit %

Data Analysis Initial 60% Treated With An Antibiotic (80%) 50% Treated The Same Day (44%) 3% Treated The Next Day (23%) 7% Treated Day 2-5 (13%) 27% Diagnosed With Tonsillitis (16%) 7% Diagnosed with Mononucleosis (6%) 57% Follow Up Phone Calls (59%) 23% Follow Up Visit (22%)

% Before Corrective Action After Corrective Action Total Rx with Antibiotic8060 Treated Same Day4450 Treated Next Day233 Treated Day Dx as Tonsillitis1627 Dx as Mononucleosis67 F/U Phone Call5957 F/U Visit2223 Data Before & After Corrective Action

Results Overall Antibiotic Treatment Decreased 33% Next Day Treatment Significantly Reduced From 23% to 3% Treatment From Day 2-5 Decreased 47% Same Day Treatment Slightly Increased From 44% to 50% Tonsillitis Increased To 68% Follow Up Phone Calls Follow Up Visits Down 4%

Performance Goal Comparison Goal: 70% Treated Performance: 60% Treated Goal: 10% Treated/Next Day Performance 3% Treated/Next Day Goal: 10% Treated/Day2-5 Performance 7% Treated/Day 2-5

Data Analysis Improvement and Achievement of Our Performance Goals Decreased Antibiotic Usage This affects antibiotic resistance and has a positive effect on health issues Improved Quality Of Care Providing follow up visits on students who were not improving. The only antibiotic provided to students post initial visit were given at the time of follow up office visits by providers

Limitations Of Assessment Strep C Only/QI Assessment College Health Clinical Judgment Tonsillitis and Mononucleosis

FUTURE STUDY Comparing Group A Clinical Presentation to Group C Presentation Centor Criteria Predictive Method to Diagnosis Strep A Relationship In Predicting Strep C

Centor Criteria Set of 4 criteria which may be used to identify the likelihood of a Group A Strep infection in patients complaining of pharyngitis. It is a method that can be used to quickly diagnosis the probability of Strep A.

Based On 4 Criteria Fever ≥100.5 Absence Of Cough Tonsillar Exudate Tender Anterior Cervical Adenopathy

Centor Criteria Score 0-1: less than 10% Probability Not worthwhile to test. Score 2-3: Intermediate Probability Score of 2, 15% Prob. Score of 3, 32% Prob. RSA test done. You can follow with a throat cx. Score 4: 60% Probability Consider empiric antibiotic Rx. Some perform a RSA.

Presence of all 4 criteria: 40-60% prob. of GAS present Absence of all 4 criteria: negative predictive value of greater than 80% GAS not present High predictive value – Better at ruling out rather than ruling in strep throat.

Centor Criteria/application to testing on students with pharyngitis and Group C BHS Pharyngitis/ Centor Criteria EHR Implementation of guidelines for treatment of Group C BHS in the college population

Throat Facts 8/1/12-5/15/13 Point Of Care 1,425 Rapid Strep In Lab 53 Back Up Throat Cultures In Lab 401