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Should nurses in Israeli primary care clinics be expecte to manage streptococcal throat infections?
Public Health (199$), |09, 347-351
© t995TheSocietyof Public Health. AII rightsreserved0033;3506/%$
Should nurses in Israeli primary care clinics be expect~ to manage streptococcal throat infections? E Kahan 1'2, T Appelbaum 2"3, H Bograd 2'3, P Shahaf 2'3 and M A Weingarten 2,3 7Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 2Institute for Occupational Health, Sackler Facu, of Medicine, Tel Aviv University, Tel Aviv, Israel; 3Department of Family Medicine, Beifinson Medical Center, Petah Tiqva, Israel
Introduction: Legal regulations in Israel allow nurses to perform only limited clinical procedures. Objective: To determine the probability of streptococcal infection in adults with sore throat, as assessed clinically by standard nursing procedures. Design: Using throat culture as the standard, the contribution of various clinical findings (fever, exudate, erythrocyte sedimentation rate (ESR), white blood count) to the determination of the diagnosis of streptococcal infection was assessed, using logistic regression analysis. Setting: Israeli general practice. Patients: 100 consecutive adult patients presenting with a red, sore throat. Results: Six patients showed the full clinical picture of exndate, increased ESR and lenkocytosis, with an 82% probability of streptococcal infection. Forty-nine patients showed none of these three findings, and only one of them (among the three patients with rhinitis) had a positive throat swab. Forty-five patients Showed an intermediate clinical picture which did not provide a reliable basis for the diagnosis or .exclusion of streptococcal infection. Fever alone did not significantly (P < 0.05) predict streptococcal infection. Conclusions: Nurses may safely discharge adult patients with a red, sore throat without antibiotic treatment only if they have no additional signs or symptoms. The few patients with all the clinical findings may be treated with antibiotics without a throat swab. All other patients should be referred for examination by a doctor. Keywords: infectious diseases; streptococcal infection; sore throat Introduction
S o r e throat is generally a trivial and self-limiting c o m p l a i n t in adults, but in som~ cases is a p r e s e n t i n g s y m p t o m of s t r e p t o c o c c a l infection. E v i d e n c e has i n d i c a t e d t h a clinical assessment alone can predict only 65% of cases and is t h e r e f o r e i n a d e q u a t ( f o r distinguishing b e t w e e n streptococcal and viral sore throat. 1-3 T h e A m e r i c a n Hear~ A s s o c i a t i o n and m a n y o t h e r authorities r e c o m m e n d that a throat swab be p e r f o r m e d in every case of sore throat. 4-9 In m a n y Israeli c o m m u n i t y h e a l t h centres, nurses act to s o m e e x t e n t as p h y s i c i a n s assistants o r nurse practitioners and can solve patients" p r o b l e m s w i t h o u t their n e e d i n g to see a d o c t o r in person. H o w e v e r , t h e y are n o t a u t h o r i s e d to use t h e antigen kits f o r rapid d e t e c t i o n o f s t r e p t o c o c c u s in throat swabs. T h e r e f o r e , b a c t e r i o logical testing in Israel involves the use o f r e g i o n a l l a b o r a t o r i e s , with all tile logistics Correspondence: Dr Ernesto Kahan, Head of Epidemiology, Department of Family Medicine, Beiliuson Medical Center, Petah Tiqva 49100, Israel Accepted for publication: 15 May 1995
Nurses and streptococcal throat infections
EKahanet a/ 348
and delays that this implies. We studied the probability of streptococcal infection in adults presenting with red, sore throat, based on the presence of fever and exudate a n d the results of two simple blood tests, for erythrocyte sedimentation rate (ESR) and total white blood cell count (WBC), which in some clinics are available immediately at the nurse's request. Patients and methods The study was conducted in one suburban family practice clinic. One hundred consecutive adult patients (62 women and 38 men) complaining of pain on swallowing or sore throat were studied. Mean age of the patients was 36 years (range, 14-71 years), All had erythema of the oropharynx on examination. The following clinical and laboratory findings were recorded and were classified as negative or positive on the basis of the following operational definitions: (1) fever per os 37.5 C, reported by the patient; (2) rhmms, if a nasal discharge was present; (3) presence of tonsiUar exudate; (4) ESR > 20 mm/hr; (5) WBC > 10000/ram. 3 This classification was chosen in order to adapt our study to the circumstances of the day.-to-day evaluation of patients by nurses. Throat cultures were collected and incubated immediately at a central laboratory close to the clinic. Readings were made after 24 hours' incubation and antibiotic sensitivity discs were used for identification. We constructed two-by-two tables to calculate sensitivity, specificity and predictive values for each variable in relation to the results of the throat cultures. We then performed a stepwise logistic regression analysis to identify which clinical findings made an independent contribution to tile prediction of the results of the throat culture. The product of this process was a logistic function in which the clinical findings (symptoms, signs and laboratory tests) were the predictor variables and the throat culture result was the dependent variable. All computations were clone on an IBM computer using BMDF statistical software. o
.
.
.
.
.
.
Results
The distribution of clinical findings was as follows: (1) fever, 31% of patients; (2) rhinitis, 6% (3) tonsillar exudate, 30%; (4) high ESR, 27%; (5) high WBC, 25%. In all, 24% of the patients had positive throat cultures for streptococcus. Owing to the low frequency of rhinitis, this finding was excluded from the analysis. "Fable 1 shows the sensitivity, specificity and predictive value for streptococcal detection for each clinical finding. Fever was found not to be a significant predictor variable for streptococcal infection (P > 0,05). Results for the other significant predictor variables ( P < 0.05) were as follows: (1) tonsillar exudate, logistic coefficient, 0.58; (2) high ESR, logistic coefficient, 0:55; and (3) high WBC, logistic coefficient, 1.08. The positive predictive Table 1 Sensitivity, specificity and positive predictive value of clinicat findings Variable Fever (> 37.5 °C) Exudate ESR > 20 rnm/hr WBC > I0000/mm 3
Sensitivity
Specificity
Positive predictive value
0.62 0.68 0,42 0.65
0.77 0.80 0.g5 0.85
0.42 0.50 0.40 0.65
Nurses and streptococcal throat inf¢
E Kahanet al
value of the different combinations of findings (Table 2) ranged from 0 in the pati without a n y o f the specific findings to 1.00 in the patients exhibiting all three ot above signs: tonsillar exudate, increased ESR and teukocytosis. Table 3 shows how the positive throat cultures correlate with different combinat of clinical findings. Discussion
Twenty years ago Greenfield et aP ° provided a protocol for a standardised cli~ assessment for physician extenders to predict accurately which patients with ,' throat were at risk of streptococcal infection and required bacteriological testin~ treatment b y a physician. Since then, m a n y similar attempts at developing a prot( h a v e been made I>t7 culminating in the Medical College of Virginia (MCV) decL, r u l e ? 8 a clinical pattern of tonsitlar exudate, cervical lymphadenopathy and fever the absence of cough, has a discriminatory power (area u n d e r the receiver opera~ curve) of 0.78 (theoretical maximum, 1,00). Although this rule has been u repeatedly in subsequent studies, a9-2~ it is inapplicable in Israel and surely in m~ other countries where nurses work under strictly defined legal limitations and are
Table
2 Probability of streptococcal infection for different combinations of clinical finding,
Clinical findings
n
Positive throat culture for streptococcus
Positive predictive value for different combinations
None One Two Three
46 30 16 8
0 8-18 4-16 8
0 0.27-0.60 0.25-1.00 1.00
Note: *Tonsillarexudate, elevated sedimentationrate or leukocytosis. Table 3 Probability of streptococcal infection in different combinations of clinical findings patients with sore throat and erythema
Presence of clinical findings* Rhinitis . +
Tonsilar exudate .
. -
Elevated ESR
WBC > 10 000
. -
-
-
-
+
-
-
+
-
-
-
+
+
+ -
No. of patients" 46 3 11 11 5 4
Strep. positive (%) 0 33 27 27 60 25
-
+
-
+
4
50
-
-
+
+
7
57
+ +
+ + +
+ -
-+ +
1 6 2
100 66 100
Probability of positive streptoeocc. infection** -0.45 0.14 0.14 0.32 0:35 0 , 60 0,59
0:72 0.82 0,95
Notes: *Fever was excluded from the analysis because of tack of significanteffect (P> 0.05) on positiv streptococcal infection (positivethroat culture). **Probabilityestimatedby logisticregression analysis
E Kahanet al
Nurses and streptococcal throat infections
150
qualified to assess cervical lymphadenopathy. They can, however, measure temperature, inspect the throat and take venous blood samples. Although the availability of rapid antigen tests for immediate bacteriological testing has changed the pattern of care of sore throats, the common existence of the carrier state means' that the presence of streptococcus is not equal to its incrimination as the cause of illness. The increasing popularity of near-patient testing, where tests are performed at the time of consultation and the results are immediately available, has resulted in the addition of blood tests, indicating an active infectious reaction, to the clinical assessment. 22 C-reactive protein level and the leukocyte count have shown equal discriminatory ability, ESR considerably lower ability, and immunological tests (AST and ADNase B) considerably higher. In Israel, only the ESR and the leukocyte count are generally available immediately. Our findings are limited to adults. In children the considerations may be quite different because of concern about the development of poststreptococcal rheumatic fever.23 De Neef 24 presented a selective management strategy according to individual utility scales. He noted that, in some clinical situations--for example, in cases of recurrent infection or family clustering--immediate treatment is important even in the face of diagnostic uncertainty. Centor 25 pointed out that even a slight shortening of disease duration may be highly desirable to the patient (and to the economy), and justify treatment even when rheumatic fever is highly unlikely to occur. Similarly, I-I~llner and Centor 26 showed that, at certain probabilities, the benefits of treating all patients with streptococcus outweigh the adverse effects of treating many others who also prove to be infection-free, on the assumption that the biological and economic costs of unnecessary antibiotic treatment are particularly low. Although the majority of cases fall into the category where clinical assessment alone cannot diagnose streptococcal infection with confidence, the risk of rheumatic fever, if the diagnosis is missed, is nevertheless very low indeed. In these cases other considerations are paramount in deciding for or against treatment without the benefit of bacteriological testing, such as in-family infectivity, desirability of shortening the duration of the illness, coexistence of chronic disease, etc. These are the sort of considerations which only a doctor may take into account. Our results may serve to clarify the potential role of nurse triage in the management of sore throats. Since 46% of all patients showed none of the signs or symptoms predictive of streptococcal infection, nurses may safely discharge this group without further medical examination. On the other hand, since only 6% of all patients showed the full clinical picture, where the probability of streptococcal infection is 82%, nurses cannot be expected to make the diagnosis of streptococcal infection on clinical grounds alone. Therefore, all patients with any positive clinical findings beyond erythema should be referred to a doctor.
References
I Irvine DA. The general practitioner and upper respiratory tract infection in childhood. Faro Pract 1986; 3: 126.13L 2 R ~ R, Bitnun S. Dilemmas of streptococcal pharyngitis. A m Faro Physician 1987; 35: 187-192. 3 H~ffmann S. Diagnosis of streptococcal tonsillitis in general practice by clinical assessment andby office culture of throat swabs:on StrepmcuAt. Infection t987; 15: tt5-118: 4 Shires DB, Hennen BK. Family Medicine: A Guidebook for Practitioners of the Art. McGraw-Hilt: New York, t980. 5 Bisno AL. Treating the patient with sore throat: theory vs. practice, JAMA 1983; 250: 2351. 6 Dillon HC. Streptococcal pharyngitis in the 1980s. Paediatr Infect Dis J 1987; 6: 123-130,
EKahanet al
Nurses and streptococcal throat infe¢
7 Heckerling PS, Harris AA. Streptococcal pharyngitis in an adult emergency room pop~ tion. J Faro Pract 1988: 21: 302-307. 8 Tanz RR, Shulman ST. Streptococcal pharyngitis. Postgrad Med 1988; 84: 203-213. 9 Wald ER. Management of pharyngitis revisited. J Faro Pract 1988: 26: 367-368. 10 Greenfield S, Bragg FE. McCraith DL. Blackburn J. Upper respiratory tract compl~ protocol for physician~extenders. Arch Intern Med 1974; 133: 294-299. 11 Walsh BT, Bookheim WW, Johnson RC. Tompkins RK. Recognition of streptococ pharyngitis in adults. Arch Intern Mecl 1975; 135: 1493-1497. 12 Breese AB. A simple scorecard for the tentative diagnosis of streptococcal pharyngl: A m J Dis Child 1977; 131: 514-517. 13 Komaroff AL. A management strategy for sore throat. J A M A 1978: 239: 1429-1432. 14 Wood RW, Tompkins RK, Wolcott BW. An efficient strategy for managing act respiratory illness in adults, A n n Intern Med 1980; 93: 757-763. 15 Roos K. The diagnostic value of symptoms and signs in acute tonsillitis in children over age of 10 and adults. Scand J Infect Dis 1985; 17: 259-267. 16 Reed BD, Huck W, French T. Diagnosis of group A /3-haemolytic streptococcus usi clinical scoring criteria. Directigen 1-2-3 group A Streptococcal test and culttlre. Arch Inte Med 1990; lg0: 1717-1732. 17 Hoffmann S. An algorithm for a selective use of throat swabs in the diagnosis of group streptococcal pharyngo-tonsillitis in general practice. Scand J Prim Health Care 1992:1 295-306. 18 Centor R M et al. The diagnosis of strep throat in adults in the emergency room. M e d Dec Making 1981; 1: 239-246. 19 Wigton RS, Connor JL, Centor RM. Transportability of a decision rule for the diagnosis c streptococcal pharyngitis. Arch Intern M e d 1986; 146: 81-83. 20 De Neef P. Comparison of tests for streptococcal pharyngitis. J Faro Pract 1986; 22 551-555. 21 Dagnelie CF et al. Bacterial flora in patients presenting with sore throat in Dutch gener~ practice. Farn Pract 1993; 10: 371-377. 22 Hjordtahl P, Melbye H. Does near-to-patient testing contribute to the diagnosis c streptococcal pharyngitis in adults? Scand J Prim Health Care 1994; 12: 70-76. 23 Herz MJ. Antibiotic and the adult sore throat--an unnecessary ceremony. Faro Pract 1988 5: 196-199. 24 De Neef P. Use of a clinical decision rule to diagnose streptococcal pharyngitis in hospita employees. A m . J Infect Control 1988; 16: 60-65. 25 Centor RM. Strategies for treating sore throat in adults. J Faro Pract 1987; 25: 335-336. 26 Hillner BE, Centor RM. What a difference a day makes: the importance of tt~rnaround time of diagnostic tests in sore throats. J Gen Intern M e d t987; 2: 244-250.
© t995TheSocietyof Public Health. AII rightsreserved0033;3506/%$
Should nurses in Israeli primary care clinics be expect~ to manage streptococcal throat infections? E Kahan 1'2, T Appelbaum 2"3, H Bograd 2'3, P Shahaf 2'3 and M A Weingarten 2,3 7Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 2Institute for Occupational Health, Sackler Facu, of Medicine, Tel Aviv University, Tel Aviv, Israel; 3Department of Family Medicine, Beifinson Medical Center, Petah Tiqva, Israel
Introduction: Legal regulations in Israel allow nurses to perform only limited clinical procedures. Objective: To determine the probability of streptococcal infection in adults with sore throat, as assessed clinically by standard nursing procedures. Design: Using throat culture as the standard, the contribution of various clinical findings (fever, exudate, erythrocyte sedimentation rate (ESR), white blood count) to the determination of the diagnosis of streptococcal infection was assessed, using logistic regression analysis. Setting: Israeli general practice. Patients: 100 consecutive adult patients presenting with a red, sore throat. Results: Six patients showed the full clinical picture of exndate, increased ESR and lenkocytosis, with an 82% probability of streptococcal infection. Forty-nine patients showed none of these three findings, and only one of them (among the three patients with rhinitis) had a positive throat swab. Forty-five patients Showed an intermediate clinical picture which did not provide a reliable basis for the diagnosis or .exclusion of streptococcal infection. Fever alone did not significantly (P < 0.05) predict streptococcal infection. Conclusions: Nurses may safely discharge adult patients with a red, sore throat without antibiotic treatment only if they have no additional signs or symptoms. The few patients with all the clinical findings may be treated with antibiotics without a throat swab. All other patients should be referred for examination by a doctor. Keywords: infectious diseases; streptococcal infection; sore throat Introduction
S o r e throat is generally a trivial and self-limiting c o m p l a i n t in adults, but in som~ cases is a p r e s e n t i n g s y m p t o m of s t r e p t o c o c c a l infection. E v i d e n c e has i n d i c a t e d t h a clinical assessment alone can predict only 65% of cases and is t h e r e f o r e i n a d e q u a t ( f o r distinguishing b e t w e e n streptococcal and viral sore throat. 1-3 T h e A m e r i c a n Hear~ A s s o c i a t i o n and m a n y o t h e r authorities r e c o m m e n d that a throat swab be p e r f o r m e d in every case of sore throat. 4-9 In m a n y Israeli c o m m u n i t y h e a l t h centres, nurses act to s o m e e x t e n t as p h y s i c i a n s assistants o r nurse practitioners and can solve patients" p r o b l e m s w i t h o u t their n e e d i n g to see a d o c t o r in person. H o w e v e r , t h e y are n o t a u t h o r i s e d to use t h e antigen kits f o r rapid d e t e c t i o n o f s t r e p t o c o c c u s in throat swabs. T h e r e f o r e , b a c t e r i o logical testing in Israel involves the use o f r e g i o n a l l a b o r a t o r i e s , with all tile logistics Correspondence: Dr Ernesto Kahan, Head of Epidemiology, Department of Family Medicine, Beiliuson Medical Center, Petah Tiqva 49100, Israel Accepted for publication: 15 May 1995
Nurses and streptococcal throat infections
EKahanet a/ 348
and delays that this implies. We studied the probability of streptococcal infection in adults presenting with red, sore throat, based on the presence of fever and exudate a n d the results of two simple blood tests, for erythrocyte sedimentation rate (ESR) and total white blood cell count (WBC), which in some clinics are available immediately at the nurse's request. Patients and methods The study was conducted in one suburban family practice clinic. One hundred consecutive adult patients (62 women and 38 men) complaining of pain on swallowing or sore throat were studied. Mean age of the patients was 36 years (range, 14-71 years), All had erythema of the oropharynx on examination. The following clinical and laboratory findings were recorded and were classified as negative or positive on the basis of the following operational definitions: (1) fever per os 37.5 C, reported by the patient; (2) rhmms, if a nasal discharge was present; (3) presence of tonsiUar exudate; (4) ESR > 20 mm/hr; (5) WBC > 10000/ram. 3 This classification was chosen in order to adapt our study to the circumstances of the day.-to-day evaluation of patients by nurses. Throat cultures were collected and incubated immediately at a central laboratory close to the clinic. Readings were made after 24 hours' incubation and antibiotic sensitivity discs were used for identification. We constructed two-by-two tables to calculate sensitivity, specificity and predictive values for each variable in relation to the results of the throat cultures. We then performed a stepwise logistic regression analysis to identify which clinical findings made an independent contribution to tile prediction of the results of the throat culture. The product of this process was a logistic function in which the clinical findings (symptoms, signs and laboratory tests) were the predictor variables and the throat culture result was the dependent variable. All computations were clone on an IBM computer using BMDF statistical software. o
.
.
.
.
.
.
Results
The distribution of clinical findings was as follows: (1) fever, 31% of patients; (2) rhinitis, 6% (3) tonsillar exudate, 30%; (4) high ESR, 27%; (5) high WBC, 25%. In all, 24% of the patients had positive throat cultures for streptococcus. Owing to the low frequency of rhinitis, this finding was excluded from the analysis. "Fable 1 shows the sensitivity, specificity and predictive value for streptococcal detection for each clinical finding. Fever was found not to be a significant predictor variable for streptococcal infection (P > 0,05). Results for the other significant predictor variables ( P < 0.05) were as follows: (1) tonsillar exudate, logistic coefficient, 0.58; (2) high ESR, logistic coefficient, 0:55; and (3) high WBC, logistic coefficient, 1.08. The positive predictive Table 1 Sensitivity, specificity and positive predictive value of clinicat findings Variable Fever (> 37.5 °C) Exudate ESR > 20 rnm/hr WBC > I0000/mm 3
Sensitivity
Specificity
Positive predictive value
0.62 0.68 0,42 0.65
0.77 0.80 0.g5 0.85
0.42 0.50 0.40 0.65
Nurses and streptococcal throat inf¢
E Kahanet al
value of the different combinations of findings (Table 2) ranged from 0 in the pati without a n y o f the specific findings to 1.00 in the patients exhibiting all three ot above signs: tonsillar exudate, increased ESR and teukocytosis. Table 3 shows how the positive throat cultures correlate with different combinat of clinical findings. Discussion
Twenty years ago Greenfield et aP ° provided a protocol for a standardised cli~ assessment for physician extenders to predict accurately which patients with ,' throat were at risk of streptococcal infection and required bacteriological testin~ treatment b y a physician. Since then, m a n y similar attempts at developing a prot( h a v e been made I>t7 culminating in the Medical College of Virginia (MCV) decL, r u l e ? 8 a clinical pattern of tonsitlar exudate, cervical lymphadenopathy and fever the absence of cough, has a discriminatory power (area u n d e r the receiver opera~ curve) of 0.78 (theoretical maximum, 1,00). Although this rule has been u repeatedly in subsequent studies, a9-2~ it is inapplicable in Israel and surely in m~ other countries where nurses work under strictly defined legal limitations and are
Table
2 Probability of streptococcal infection for different combinations of clinical finding,
Clinical findings
n
Positive throat culture for streptococcus
Positive predictive value for different combinations
None One Two Three
46 30 16 8
0 8-18 4-16 8
0 0.27-0.60 0.25-1.00 1.00
Note: *Tonsillarexudate, elevated sedimentationrate or leukocytosis. Table 3 Probability of streptococcal infection in different combinations of clinical findings patients with sore throat and erythema
Presence of clinical findings* Rhinitis . +
Tonsilar exudate .
. -
Elevated ESR
WBC > 10 000
. -
-
-
-
+
-
-
+
-
-
-
+
+
+ -
No. of patients" 46 3 11 11 5 4
Strep. positive (%) 0 33 27 27 60 25
-
+
-
+
4
50
-
-
+
+
7
57
+ +
+ + +
+ -
-+ +
1 6 2
100 66 100
Probability of positive streptoeocc. infection** -0.45 0.14 0.14 0.32 0:35 0 , 60 0,59
0:72 0.82 0,95
Notes: *Fever was excluded from the analysis because of tack of significanteffect (P> 0.05) on positiv streptococcal infection (positivethroat culture). **Probabilityestimatedby logisticregression analysis
E Kahanet al
Nurses and streptococcal throat infections
150
qualified to assess cervical lymphadenopathy. They can, however, measure temperature, inspect the throat and take venous blood samples. Although the availability of rapid antigen tests for immediate bacteriological testing has changed the pattern of care of sore throats, the common existence of the carrier state means' that the presence of streptococcus is not equal to its incrimination as the cause of illness. The increasing popularity of near-patient testing, where tests are performed at the time of consultation and the results are immediately available, has resulted in the addition of blood tests, indicating an active infectious reaction, to the clinical assessment. 22 C-reactive protein level and the leukocyte count have shown equal discriminatory ability, ESR considerably lower ability, and immunological tests (AST and ADNase B) considerably higher. In Israel, only the ESR and the leukocyte count are generally available immediately. Our findings are limited to adults. In children the considerations may be quite different because of concern about the development of poststreptococcal rheumatic fever.23 De Neef 24 presented a selective management strategy according to individual utility scales. He noted that, in some clinical situations--for example, in cases of recurrent infection or family clustering--immediate treatment is important even in the face of diagnostic uncertainty. Centor 25 pointed out that even a slight shortening of disease duration may be highly desirable to the patient (and to the economy), and justify treatment even when rheumatic fever is highly unlikely to occur. Similarly, I-I~llner and Centor 26 showed that, at certain probabilities, the benefits of treating all patients with streptococcus outweigh the adverse effects of treating many others who also prove to be infection-free, on the assumption that the biological and economic costs of unnecessary antibiotic treatment are particularly low. Although the majority of cases fall into the category where clinical assessment alone cannot diagnose streptococcal infection with confidence, the risk of rheumatic fever, if the diagnosis is missed, is nevertheless very low indeed. In these cases other considerations are paramount in deciding for or against treatment without the benefit of bacteriological testing, such as in-family infectivity, desirability of shortening the duration of the illness, coexistence of chronic disease, etc. These are the sort of considerations which only a doctor may take into account. Our results may serve to clarify the potential role of nurse triage in the management of sore throats. Since 46% of all patients showed none of the signs or symptoms predictive of streptococcal infection, nurses may safely discharge this group without further medical examination. On the other hand, since only 6% of all patients showed the full clinical picture, where the probability of streptococcal infection is 82%, nurses cannot be expected to make the diagnosis of streptococcal infection on clinical grounds alone. Therefore, all patients with any positive clinical findings beyond erythema should be referred to a doctor.
References
I Irvine DA. The general practitioner and upper respiratory tract infection in childhood. Faro Pract 1986; 3: 126.13L 2 R ~ R, Bitnun S. Dilemmas of streptococcal pharyngitis. A m Faro Physician 1987; 35: 187-192. 3 H~ffmann S. Diagnosis of streptococcal tonsillitis in general practice by clinical assessment andby office culture of throat swabs:on StrepmcuAt. Infection t987; 15: tt5-118: 4 Shires DB, Hennen BK. Family Medicine: A Guidebook for Practitioners of the Art. McGraw-Hilt: New York, t980. 5 Bisno AL. Treating the patient with sore throat: theory vs. practice, JAMA 1983; 250: 2351. 6 Dillon HC. Streptococcal pharyngitis in the 1980s. Paediatr Infect Dis J 1987; 6: 123-130,
EKahanet al
Nurses and streptococcal throat infe¢
7 Heckerling PS, Harris AA. Streptococcal pharyngitis in an adult emergency room pop~ tion. J Faro Pract 1988: 21: 302-307. 8 Tanz RR, Shulman ST. Streptococcal pharyngitis. Postgrad Med 1988; 84: 203-213. 9 Wald ER. Management of pharyngitis revisited. J Faro Pract 1988: 26: 367-368. 10 Greenfield S, Bragg FE. McCraith DL. Blackburn J. Upper respiratory tract compl~ protocol for physician~extenders. Arch Intern Med 1974; 133: 294-299. 11 Walsh BT, Bookheim WW, Johnson RC. Tompkins RK. Recognition of streptococ pharyngitis in adults. Arch Intern Mecl 1975; 135: 1493-1497. 12 Breese AB. A simple scorecard for the tentative diagnosis of streptococcal pharyngl: A m J Dis Child 1977; 131: 514-517. 13 Komaroff AL. A management strategy for sore throat. J A M A 1978: 239: 1429-1432. 14 Wood RW, Tompkins RK, Wolcott BW. An efficient strategy for managing act respiratory illness in adults, A n n Intern Med 1980; 93: 757-763. 15 Roos K. The diagnostic value of symptoms and signs in acute tonsillitis in children over age of 10 and adults. Scand J Infect Dis 1985; 17: 259-267. 16 Reed BD, Huck W, French T. Diagnosis of group A /3-haemolytic streptococcus usi clinical scoring criteria. Directigen 1-2-3 group A Streptococcal test and culttlre. Arch Inte Med 1990; lg0: 1717-1732. 17 Hoffmann S. An algorithm for a selective use of throat swabs in the diagnosis of group streptococcal pharyngo-tonsillitis in general practice. Scand J Prim Health Care 1992:1 295-306. 18 Centor R M et al. The diagnosis of strep throat in adults in the emergency room. M e d Dec Making 1981; 1: 239-246. 19 Wigton RS, Connor JL, Centor RM. Transportability of a decision rule for the diagnosis c streptococcal pharyngitis. Arch Intern M e d 1986; 146: 81-83. 20 De Neef P. Comparison of tests for streptococcal pharyngitis. J Faro Pract 1986; 22 551-555. 21 Dagnelie CF et al. Bacterial flora in patients presenting with sore throat in Dutch gener~ practice. Farn Pract 1993; 10: 371-377. 22 Hjordtahl P, Melbye H. Does near-to-patient testing contribute to the diagnosis c streptococcal pharyngitis in adults? Scand J Prim Health Care 1994; 12: 70-76. 23 Herz MJ. Antibiotic and the adult sore throat--an unnecessary ceremony. Faro Pract 1988 5: 196-199. 24 De Neef P. Use of a clinical decision rule to diagnose streptococcal pharyngitis in hospita employees. A m . J Infect Control 1988; 16: 60-65. 25 Centor RM. Strategies for treating sore throat in adults. J Faro Pract 1987; 25: 335-336. 26 Hillner BE, Centor RM. What a difference a day makes: the importance of tt~rnaround time of diagnostic tests in sore throats. J Gen Intern M e d t987; 2: 244-250.