AAP Voices Blog

I love talking about group A streptococcal pharyngitis.

I know, that sounds a bit odd, and it’s not an exciting subject for most conversations. But this is one of the most common childhood infections for which there is a test to make the diagnosis, which lends itself to quality improvement work. It also allows us to talk about the very important subject of antibiotic use.

Every month I give a short didactic session for our pediatric residents rotating on the infectious diseases consult service on pharyngitis at the hospital I work at, Children’s Mercy in Kansas City. The residents have an interactive module to review, and then when we meet, I can answer their questions and to pose questions to get them thinking about:

• How they decide which patients should be tested
• Why treat strep pharyngitis in the first place?
• What is the actual risk of acute rheumatic fever in the U.S.?
• How much faster do you get better if treated for strep throat?

I give everyone a chance to answer. They often compete as if this is “The Price Is Right” and the one closest to the right answer gets the new car. Even though there are no new cars, it is still fun. I love getting a wide range of answers and seeing the new knowledge being absorbed right in front of me.

“As the CDC notes, everyone can help improve antibiotic prescribing and use.”

As a junior faculty member, I became involved with our antimicrobial stewardship program, and group A streptococcal pharyngitis seemed the perfect diagnosis in which to collaborate with our Emergency Department and community pediatric practices.

Nearly all clinicians use either penicillin or amoxicillin to treat streptococcal pharyngitis, so there is very little work to be done there. However, there is interesting work to be done in the field of diagnostic stewardship to reduce testing in children at very low risk of GAS pharyngitis. In general, children under 3 years of age and those with viral respiratory symptoms (for instance, cough and congestion) are very unlikely to have GAS pharyngitis.

This work led me to collaborate with colleagues in infectious diseases and the AAP to create Education in Quality Improvement for Pediatric Practice (EQIPP) modules on the diagnosis and treatment of common respiratory conditions in children. There are four modules, including upper respiratory viral infections, acute bacterial sinusitis, acute otitis media, and GAS pharyngitis. These modules provide a ready-made quality improvement project for pediatric practices looking to improve an aspect of clinical care, while also earning CME and MOC part 4 points from the American Board of Pediatrics. These modules were developed in 2015 and recently were updated and re-launched in October 2021.

While GAS pharyngitis is a seemingly simple infection that is diagnosed every day, it can be a difficult diagnosis to make because it can also be a colonizing organism. Additionally, clinicians have the added burden of convincing a worried parent that their child’s symptoms are viral in nature and that a strep test won’t be helpful and may confuse the picture.

These discussions with families are often nuanced around the risk of missing strep throat in a child with viral symptoms vs. the risk of an adverse reaction to an unnecessary antibiotic.

Seeing the residents discover a new way to frame this conversation is very interesting and I hope they take something away from our sessions. Maybe a little more knowledge. But, more importantly, how to discuss risk vs. benefit regarding testing in a patient who is very unlikely to have the infection.

Antibiotic Awareness Week is Nov. 18-24, 2021, an annual observance that raises awareness of the threat of antibiotic resistance and the importance of appropriate antibiotic use. As the CDC notes, everyone can help improve antibiotic prescribing and use.

During this week, I hope you take a moment to look at the resources on the CDC website, make a commitment to learn one new stewardship practice to share with your group, or consider completing one of the EQIPP modules as a quality improvement project in your practice.