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Diagnostic accuracy of FEVER-Pain and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial

Diagnostic accuracy of FEVER-Pain and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial
Diagnostic accuracy of FEVER-Pain and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial
Background: Sore throat is a common and self-limiting condition. There remains ambiguity in stratifying patients to immediate, delayed or no antibiotic prescriptions. NICE recommends two clinical prediction rules (CPRs), FeverPAIN and CENTOR, to guide decision-making. Aim: Describe the diagnostic accuracy of CPRs in identifying streptococcal throat infections. Design and Setting: Adults presenting to UK primary care with sore throat, who did not require immediate antibiotics. Methods: As part of the Treatment Options without Antibiotics for Sore Throat (TOAST) trial, 565 participants, aged ≥ 18, were recruited on day of presentation to general practice. Physicians could opt to give delayed prescriptions. CPR scores were not part of the trial protocol but calculated post-hoc from baseline assessments. Diagnostic accuracy was calculated by comparing scores to throat swab cultures. Results: 81/502 (16.1%) of patients had Group A, C or G streptococcus cultured on throat swab. Overall diagnostic accuracy of both CPRs was poor: area under receiver-operating-characteristics curve 0.62 for Centor; 0.59 for FeverPAIN. Post-test probability of a positive or negative test was 27.3% (95% confidence intervals: 6.0-61.0%) and 84.1% (80.6-87.2%) for FeverPAIN ≥4, versus 25.7% (16.2-37.2%) and 85.5% (81.8-88.7%) for Centor ≥3. Higher CPR scores were associated with increased delayed antibiotic prescriptions (2 = 8.42, p=0.004 for FeverPAIN ≥4; 2 = 32.0, p<0.001 for Centor ≥3). Conclusions: In those that do not require immediate antibiotics in primary care, neither CPR provide a reliable way of diagnosing streptococcal throat infection. However, clinicians were more likely to give delayed prescriptions to those with higher scores.
Seeley, Anna
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Fanshawe, Thomas R.
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Voysey, Merryn
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Hay, Alistair D.
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Moore, Michael
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Hayward, Gail
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Seeley, Anna
ad4700a9-696d-48ab-a52f-3e11776e2a48
Fanshawe, Thomas R.
7cb37df5-a324-485c-90bb-6640124e6c48
Voysey, Merryn
fd9bd72b-7aaf-4390-a27f-bd8a6e6d92ae
Hay, Alistair D.
4ac520e7-944a-4732-b074-5436b4570f76
Moore, Michael
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Hayward, Gail
cdcca43f-3ee3-4094-a16b-a51b1585e9ed

Seeley, Anna, Fanshawe, Thomas R., Voysey, Merryn, Hay, Alistair D., Moore, Michael and Hayward, Gail (2021) Diagnostic accuracy of FEVER-Pain and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial. BJGP Open, 5 (6). (doi:10.3399/BJGPO.2021.0122).

Record type: Article

Abstract

Background: Sore throat is a common and self-limiting condition. There remains ambiguity in stratifying patients to immediate, delayed or no antibiotic prescriptions. NICE recommends two clinical prediction rules (CPRs), FeverPAIN and CENTOR, to guide decision-making. Aim: Describe the diagnostic accuracy of CPRs in identifying streptococcal throat infections. Design and Setting: Adults presenting to UK primary care with sore throat, who did not require immediate antibiotics. Methods: As part of the Treatment Options without Antibiotics for Sore Throat (TOAST) trial, 565 participants, aged ≥ 18, were recruited on day of presentation to general practice. Physicians could opt to give delayed prescriptions. CPR scores were not part of the trial protocol but calculated post-hoc from baseline assessments. Diagnostic accuracy was calculated by comparing scores to throat swab cultures. Results: 81/502 (16.1%) of patients had Group A, C or G streptococcus cultured on throat swab. Overall diagnostic accuracy of both CPRs was poor: area under receiver-operating-characteristics curve 0.62 for Centor; 0.59 for FeverPAIN. Post-test probability of a positive or negative test was 27.3% (95% confidence intervals: 6.0-61.0%) and 84.1% (80.6-87.2%) for FeverPAIN ≥4, versus 25.7% (16.2-37.2%) and 85.5% (81.8-88.7%) for Centor ≥3. Higher CPR scores were associated with increased delayed antibiotic prescriptions (2 = 8.42, p=0.004 for FeverPAIN ≥4; 2 = 32.0, p<0.001 for Centor ≥3). Conclusions: In those that do not require immediate antibiotics in primary care, neither CPR provide a reliable way of diagnosing streptococcal throat infection. However, clinicians were more likely to give delayed prescriptions to those with higher scores.

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Sore Throat CDR secondary analysis TOAST RCT BJGP Open Revised_Clean - Accepted Manuscript
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Accepted/In Press date: 27 July 2021
e-pub ahead of print date: 22 September 2021
Additional Information: Funding This research was funded by the National Institute for Health Research (NIHR) Community Healthcare MedTech and In Vitro Diagnostics Co-operative at Oxford Health NHS Foundation Trust and the NIHR School for Primary Care Research (SPCR Grant Number 172). AS is funded by a NIHR Academic Clinical Fellowship (Award number ACF-2019-13-009). AH is supported by an NIHR Senior Investigator Award (Award number NIHR200151). GH is funded by the NIHR Community Healthcare MedTech and In Vitro Diagnostics Co-operative at Oxford Health NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of NIHR or the Department of Health and Social Care.

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Local EPrints ID: 450718
URI: http://eprints.soton.ac.uk/id/eprint/450718
PURE UUID: 86ab9410-1138-4999-94c6-ddda94663b3a
ORCID for Michael Moore: ORCID iD orcid.org/0000-0002-5127-4509

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Date deposited: 09 Aug 2021 16:30
Last modified: 17 Mar 2024 03:01

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Contributors

Author: Anna Seeley
Author: Thomas R. Fanshawe
Author: Merryn Voysey
Author: Alistair D. Hay
Author: Michael Moore ORCID iD
Author: Gail Hayward

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