In this post I link to and excerpt from the Cribsiders‘ Aug 19, 2020 podcast and show notes by Dr Justin Berk, More Than Strep: Pharyngitis w/ “Uncle Bob” Centor [with additional resources from Tiny Tips: Modified Centor Score for Streptococcal Pharyngitis, Jan 18, 2017, Canadiem]:
The creator of the Centor score gives us an evidence-based discussion to the diagnosis and management of pharyngitis
Your kid’s got a sore throat–no big deal? Think again! Strep Up 2 the Streets and listen to this episode as we wade into the depths of pediatric and adolescent pharyngitis, with the world-renowned creator of the Centor Criteria Dr. Robert Centor MD, MACP, internist and Professor-Emeritus at The University of Alabama at Birmingham School of Medicine. In this episode, we discuss/review the Centor criteria, the differential diagnosis for acute pharyngitis in the school-aged versus adolescent patient, how to treat bacterial pharyngitis, and what complications to watch out for in the pediatric populations.
Here is the outstanding podcast:
Here are excerpts from the show notes:
Definition of acute pharyngitis: 1 day to 3 days. Greater than a week is no longer acute pharyngitis. With or without treatment, especially in kids, most everyone is better in 3 – 5 days.
- The differential diagnosis for pharyngitis is very different in school-aged versus adolescent/young adult patients.
- If your patient has a Centor score of 0 or 1, you do not need to do a Rapid Strep test or give antibiotics.
- Five + Potential Reasons to Treat Group A Strep
- Prevent Acute Rheumatic Fever
- Decrease probability of peritonsillar abscesses or other similar abscesses
- Decrease spread in the household (If a 7 year old has GAS, untreated, at least 50% of the other people in the household will get in)
- Prevent death
- To go back to school
- For adolescents: shortening the duration of illness
- Red Flags for Lemierre’s Syndrome*:
- Rigors (high likelihood ratio for bacteremia)
- Unilateral neck swelling (either peritonsillar abscess or Lemierre’s)
- Pulmonary symptoms
- No improvement after 5-6 days
*Lemierre’s Syndrome: Oropharyngeal infection leading to secondary septic thrombophlebitis of the internal jugular vein; Necrobacillosis
Development of Centor Criteria
The original research that led to the development of the Centor criteria came from a walk-in Emergency Department with a lot of adolescents and young adults (15-30 year olds). Based on this data, the original score was not developed with the pediatric population in mind.
Discussion of the Centor Criteria
Guidelines agree we should not overtreat nor overtest children who have pharyngitis. The real value of the Modified/McIsaac Centor Score* is telling you who to reassure. Sidenote: In the original study, the history of a fever was better than the actual temperature taken in the ER. Ask about cough and coryza, look for significant pus on tonsils and feel for anterior cervical adenopathy, both of which increase the probability of a bacterial infection.
* Modified Centor Score For Streptococcal Pharyngitis from Jan 18, 2017 from Canadiem.
Table below is from Canadiem post
For patients presenting with:
- Sore Throat
- URTI Symptoms
The following is also from the Canadiem post:
Upper Respiratory Infection symptoms like cough or sore throat are still some of the top reasons for Canadian emergency department visits, and will likely be even higher in the upcoming months and in Urgent Care Centres.1 The most common organisms responsible for uncomplicated acute pharyngitis are viral agents at 50-80% and Streptococcal agents, specifically Group A Beta-Hemolytic Strep, at 5-36%.2 It is clinically significant to differentiate between these two pathogens as patients with the latter would benefit from antibiotic therapy, and patients with the former should not have antibiotic therapy due to deriving no benefit.
Here is the mneumonic for the modified Centor decision rule (aka McIsaac Score) and the recommendations for treatment based on the Modified Centor Score from the Canadiem post:
The following is also from the Canadiem post:
Resuming excerpts from More Than Strep: Pharyngitis w/ “Uncle Bob” Centor
Should we treat GAS in children?
There is a discussion whether or not to even treat GAS in school-aged children. Dr. Centor discusses an article* that argues that since the rate of Acute Rheumatic Fever in the US is so low, the risks associated with antibiotic use is worse than the risk of ARF.
*Differences Among International Pharyngitis Guidelines: Not Just Academic [PubMed Central] [Full Text HTML] [Full Text PDF]. Ann Fam Med. Sep-Oct 2007;5(5):436-43.
The above article has been cited by 42 articles in PubMed Central.