Diagnosis and management of acute pharyngotonsillitis among pediatric patients at Ribat Teaching Hospital: a prospective audit (2021-2022)

Abstract

Diagnosis of pharyngotonsillitis is challenging due to the wide range of symptoms and signs. Sudan Federal Ministry of Health and Sudanese Association of Paediatricians, along with Sudan Heart Society reached a consensus about the clinical prediction rule which aids in diagnosing and managing bacterial pharyngotonsillitis. This audit aimed to assess doctors’ knowledge and practice regarding diagnosis and management of bacterial pharyngotonsillitis at Ribat Teaching Hospital, Khartoum, Sudan. This audit was done at Pediatric Department, Ribat Teaching Hospital, and data collection was done over 2 weeks either in the first or the second cycle. Inclusion criteria were children who presented at the emergency room and were diagnosed with acute pharyngotonsillitis. The criteria used in this audit were from Sudan guidelines for prevention, diagnosis and management of rheumatic heart disease. Regular training sessions were done between the first and second cycles. There were 19 patients in the first cycle, 17 of them (89.4%) were diagnosed clinically with bacterial pharyngotonsillitis, and 8 of these 17 (47%) were fitting the criteria. Regarding the management of bacterial pharyngotonsillitis, no patient was given the recommended antibiotics in the guidelines (0.00%). In the second cycle, there were 21 patients, of whom 11 patients were diagnosed clinically with bacterial pharyngotonsillitis (52%). Of those 11, 8 patients were fitting the criteria (72.7%), and the recommended antibiotics were given in 9 of them (82%). The current practice toward acute pharyngotonsillitis management revealed a lack of doctors’ knowledge about local guidelines which can be improved by simple ways such as posters, lectures, and focused group discussions.

INTRODUCTION

Pharyngotonsillitis is an inflammation of the pharynx and tonsils marked by the presence of pharyngeal and tonsillar redness and it is categorised into acute or chronic depending on the causative organism and the immune system of the patient. Acute pharyngotonsillitis is considered the second most commonly diagnosed illness in paediatric patients [1]. The etiology of pharyngotonsillitis is broad and includes viral causes which are the most common, bacterial, fungal and parasitic causes. Among all these different causes, bacterial infection with group A beta-hemolytic streptococcus is of utmost importance. It is the most common cause of bacterial pharyngotonsillitis and is responsible for about 25% of sore throat cases in paediatric patients all around the world, including Sudan [2].

There are various signs and symptoms of acute pharyngotonsillitis such as fever, redness of the tonsils and pharynx, headache, throat angina, enlarged and tender cervical lymph nodes and dysphagia [3]. Thus, diagnosis of pharyngotonsillitis is challenging due to the wide range of symptoms and signs associated with both bacterial and viral causes, and as a result, many clinical prediction rules (CPR) have been developed worldwide in an attempt to solve this problem [4]. Well-known examples of this CPR scoring system include Centor and Maclsaac scoring systems [5]. Another example of CPR is used in Egypt and its specificity was found to be only 40% and the sensitivity was 84% [6]. A similar one was used in Turkey and showed the same results [7].

However, in regards to the accuracy of diagnosing Group A streptococcal (GAS) pharyngotonsillitis using these clinical tools, previous studies have shown that these clinical tools did not show sufficient accuracy and were not able to pinpoint low and high-risk cases [8,9]. Also, it is stated in the literature that it is difficult to differentiate streptococcal pharyngitis from other causes of pharyngitis by clinical signs and laboratory confirmation of streptococcal infection by throat-swab culture or antigen detection is not practicable in most developing countries [10–14]. Regarding the laboratory diagnosis of GAS pharyngotonsillitis, the culture of the throat swab and rapid antigen detection test (RADT) is of great importance. Throat swab cultures have a specificity and sensitivity of 94.9% and 81.1% respectively, in contrast to RADT which has a specificity and sensitivity of 93.8% and 76.8%, respectively. Due to the relatively low sensitivity of RADT, the Centers for Disease Control and Prevention (CDC) and American Academy of Family Physicians recommend that a negative RADT result should be followed with a swab throat culture to enhance the accuracy of the diagnosis [15–17]. According to the Sudanese guidelines, the gold standard diagnostic method for diagnosing GAS pharyngotonsillitis is by using a clinical prediction rule scoring system and backing it up by a throat culture and/or RADT [2].

In Sudan RADT is not available, culture is time-consuming, and both RADT and throat culture have a high cost. As a result, Sudan Federal Ministry of Health and Sudanese Association of Paediatricians along with Sudan Heart Society reached a consensus about the clinical prediction rule which aids in diagnosing GAS pharyngotonsillitis. It states that: a child from a high-risk area with a sore throat and no runny nose/cough is diagnosed with bacterial pharyngotonsillitis. However, in order to diagnose a child from a low-risk area, sore throat and no runny nose/cough plus one of the following must be present: cervical lymph adenopathy, enlarged tonsils or exudate [18].

Management of pharyngitis depends on the cause. Management of viral pharyngotonsillitis is supportive [19]. Substantial discrepancies exist in the recommendations for the management of bacterial pharyngitis among international guidelines [4,20]. According to the CDC, the first line of treatment for GAS pharyngotonsillitis is penicillin V or amoxicillin for 10 days. A single dose of benzathine penicillin can be used as an alternative treatment [19]. The treatment of choice in Sudan is one intramuscular (IM) injection of benzathine penicillin G due to a high prevalence of rheumatic fever, and this is considered the primary prevention of rheumatic heart disease (RHD) [2]. This is the same as in Egypt, Brazil and Mexico [4].

Bacterial pharyngotonsillitis is a common and serious illness in paediatric patients. Improper diagnosis and management can lead to complications that can seriously affect the life of the child and can be fatal [21]. Over-prescription of antibiotics can lead to antibiotic resistance which is a major public health issue all around the world [21]. This study aimed to assess and improve the knowledge and practice regarding the diagnosis and management of bacterial pharyngotonsillitis among doctors at the Paediatrics Department, Ribat Teaching Hospital, Khartoum, Sudan.

MATERIALS AND METHODS

Study design

This cross-sectional study was done at the Paediatrics Department, Ribat Teaching Hospital, Khartoum, Sudan.

Study area

Ribat Teaching Hospital is one of the largest hospitals in Sudan and is located in Khartoum State. It is involved in the residency program which is organised by the Federal Ministry of Health. The study was done exclusively at the Paediatric Department which includes seven units. These units are distributed throughout the week, and each consists of one consultant or specialist, registrars, medical officers and house officers. The average numbers of registrars, medical officers, house officers and nurses working in this department are 14, 11, 79 and 15, respectively. The bed capacity of the Paediatric Department is around 40 beds and the average number of admitted patients per month is 112.

Study population and sampling

Total coverage of all children who presented at the Emergency Room during the study period was done. Inclusion criteria were children from 3 to 18 years old who presented at the Emergency Room and diagnosed clinically with acute pharyngotonsillitis. Our exclusion criteria were: patients less than 3 years and insufficient data.

Data collection

There was a selected team that investigated, validated and collected the data. Our goal was to investigate the cases for 2 weeks in the first cycle and another 2 weeks in the second cycle. Data collection started on the 27^th of November and ended on the 10^th of December 2021. After completion of the first cycle, there was a presentation for its results and proper interventions took place in the form of regular training sessions, posters that demonstrate the guidelines and focused group discussion with all department units. Data collection for the second cycle (after intervention) started on the 8^th of March and ended on the 21st of the same month 2022 Data was obtained by at least two collectors per day from 8 am to 6 pm (rush hours) and from the medical notes we collected patient’s age, sex and weight. The data collecting team observed the doctors during history taking and examination and wrote down the: clinical symptoms and examination findings related to acute pharyngotonsillitis, investigation results in the form of complete blood count (CBC), and c-reactive protein (CRP) or erythrocyte sedimentation rate (ESR). If the doctor requested a throat swab and culture or not and name, type and dose of the prescribed and the administered (given) antibiotic was recorded to find out any discrepancy between prescription and administration, and the cause of this discrepancy (if found) was written. All these data were collected in a spreadsheet to be analysed. No patient-identifiable data was recorded and kept, and all recorded data was anonymised and encrypted using commercially available software.

Criteria and standards

The criteria used for this audit were Sudan’s Guidelines for acute rheumatic fever (ARF) and RHD diagnosis, management and prevention [18]. It states that: a child from a high-risk area with a sore throat and no runny nose/cough is diagnosed with bacterial pharyngotonsillitis. However, in order to diagnose a child from a low-risk area like Khartoum, sore throat and no runny nose/cough plus one of the following must be present: cervical lymph adenopathy, enlarged tonsils or exudate. The recommended clinical criteria for diagnosing bacterial pharyngotonsillitis were compared to those used by doctors. Also, the recommended antibiotics in the guidelines were compared to those prescribed by doctors.

Interviews and training sessions

During the first cycle of this audit, there were 87 doctors practicing in the emergency room at the Paediatric Department, including 63 house officers, 13 medical officers, and 11 registrars. Regarding the second cycle, there were 74 doctors practicing in the emergency room (10 registrars, 13 medical officers and 51 house officers). In order to assess their knowledge regarding the guidelines, interviews have been conducted with doctors from all department units. These interviews (either in the first or second cycle) were held over 1 week in order to cover all units. Every doctor was informed about the audit and the purpose of this interview, and approval for participation in the interview was taken from 48 doctors (55%) in the first cycle and 43 doctors (58%) in the second cycle. These interviews were held in a closed office and took about 10 to 15 minutes for each participating doctor.

After completion of the first cycle and before starting the second one, daily training sessions were conducted in all department units. These sessions were organised by the Department of Paediatrics and the audit team. The main content of these sessions was the Sudanese guidelines for the diagnosis and management of acute bacterial pharyngotonsillitis and the importance of proper diagnosis and management [5] These sessions took about 1 week in order to cover all units.

Statistical analysis

Collected data including both qualitative data gathered through interviews, and quantitative data gathered from patients’ clinical registries was entered into Microsoft Excel software and has undergone appropriate filtering, revision and cleaning. Data were analysed utilising a simple enumeration technique and results were expressed in tables detailing findings reported for each patient individually and an overall assessment of doctors’ practice.

RESULTS

First cycle

There were 19 patients who presented to the Emergency Room at the paediatric department during the period of data collection and diagnosed clinically with acute pharyngotonsillitis. Fifteen of these were females (79%) and 4 were males (21%). The mean age was 6.8 ± 2.8 (mean ± SD) years.

In general, 17 /19 (89.5%) patients were diagnosed with bacterial pharyngotonsillitis clinically, 8/17 (47%) patients fit the guidelines criteria (47%), and there was no request for throat swab and culture to confirm the diagnosis (0/17).

Regarding investigations, CBC was available in 17 patients, and CRP and ESR were available in 9 patients. Neutrophils were high in 5 out of 8 patients (62%) of those with bacterial pharyngotonsillitis according to guidelines and total white blood cell count (TWBC) was high in 6 out of those 8 patients (75%).

Regarding the 17 patients who were diagnosed with bacterial pharyngotonsillitis, doctors did not prescribe IM benzathine penicillin to any patient (0.00%) and amoxicillin + clavulanic acid was the most commonly prescribed antibiotics (9/17, 52.9%).

On interviewing 48 doctors (7 registrars, 6 medical officers and 35 house officers) out of 87 (55%) from all departments were asked about their knowledge regarding the Sudanese guidelines of diagnosis and management of acute bacterial pharyngotonsillitis. Three of them (6%) were documented to have knowledge about the clinical prediction rule stated in the guidelines. All of them said there is no need for culture in diagnosing bacterial pharyngotonsillitis unless it was recurrent. Regarding the recommended antibiotic according to the guidelines, two of them (4%) stated it correctly.

Second cycle results

Data were collected from 21 patients who presented at the emergency room at the paediatrics department and diagnosed clinically with acute pharyngotonsillitis where 13 of them were females (62%) and 8 were males (38%). The mean age was 8.4 ± 3.3 (mean ± SD) years.

In general, 11 patients were diagnosed with acute bacterial pharyngotonsillitis clinically (52.3%) and out of them 8 patients (marked by a star) fit the guidelines criteria 8/11 (72.7%) and there was no request for throat swab and culture. See supplementary materials.

Regarding investigations, CBC was available just in 10 patients, CRP was available in one patient and ESR was available in 2 patients. See supplementary materials.

For the 11 patients who were diagnosed with acute bacterial pharngiotonsiltis doctors prescribed benzathine penicillin to 9 patients (82%), azithromycin for one patient (9%) and erythromycin for another one patient (9%). There was also a discrepancy between the prescribed and given antibiotics in three patients (27.7%).

After conducting regular training sessions about the guidelines criteria, interviews were held with 43 out of 74 doctors (58%) in the department (8 registrars, 9 medical officers and 26 house officers) and the percentages of their knowledge about the guidelines were improved to 76.7% and 93% in the knowledge about the clinical prediction rule and the recommended antibiotics, respectively (Table 1).

Table 1.

The percentages of knowledge in the first and second cycles.

Criteria	First cycle	Second cycle
Knowledge about the clinical prediction rule	(3/48) 6%	(33/43) 76.7%
Knowledge about the recommended antibiotics according to the guidelines	(2/48) 4%	(40/43) 93%

Generally, there was improvement regarding the practice of clinical diagnosis and management of acute bacterial pharyngotonsillitis in the second cycle after intervention (Table 2).

Table 2.

First and second cycles practice versus the standards.

Criteria	First cycle	Second cycle	Standard
Clinical diagnosis of acute bacterial pharyngitis-tonsillitis	47%	72.7%	90%
Prescription of the recommended antibiotics according to the guidelines (IM benzathine penicillin 1.2 million IU if weight>27 kg; 600,000 IU if weight <27 kg)	0.00%	82%	90%

DISCUSSION

Pharyngotonsilitis is a very common paediatric problem and serious complications may arise from improper diagnosis and management. RHD is a devastating consequence of ARF that is caused by GAS infection. In Sudan, RHD is one of the most common causes of admission to paediatric cardiology wards and the most common cause of death due to acquired cardiac disease in children and young adults. Proper management of GAS infection is considered as primary prevention of RHD [18]. Hence, physicians need to be aware of the proper management of acute pharyngotonsillitis and not prescribe improper unnecessary antibiotics that may increase bacterial resistance rate [22]. They need to be adherent to guidelines and not under/over-prescribe antibiotics to paediatric patients [23]. Sudan’s protocol for sore throat management uses a sensitive score for the diagnosis of bacterial pharyngitis and provides a simple way for the management of GAS infection and hence prevention of ARF and RHD [18].

Regarding the first cycle in our study, only 47% of patients with pharyngitis were diagnosed correctly according to the Sudan’s guidelines of RHD and ARF diagnosis, management, and prevention. Although this percentage is not low, it does not reflect that the right diagnosis is based on knowledge about the diagnosing guidelines and criteria. This was supported by the results that were taken from interviewing doctors to assess their knowledge about those guidelines as only few of them knew about the CPR for diagnosing acute pharyngotonsillitis. These data suggest that the reason behind this improper diagnosis is the lack of knowledge as clear improvement was reported after focused group discussion and training sessions. This is consistent with the findings from a previous study that assessed Sudanese doctors’ knowledge about the prevention of ARF and RHD and reported that doctors’ awareness was on an average level and it was raised to a good one by applying simple intervention like presenting a lecture about the topic [24]. Another study done among senior medical students in Cameron stated that 25.1% of participants had good knowledge, attitudes and practice combined on the prevention and management of RHD. They also found that lecture on RHD, the history of sore throat and study in faculty of health science was associated with good knowledge, attitudes and practices on RHD [25]. Bhatt et al [27] in their study emphasised the importance of educational sessions on this topic and showed that how the level of confidence among healthcare workers in differentiating bacterial from viral sore throat clinically increased from 64% to 92% post-session. However, even after the teaching session, most of the participants in this study believed that the most likely cause of sore throat is a bacterial infection, instead of viral. The fact that the teaching session focused on differentiating bacterial from the viral sore throat rather than specifically on the most common cause of sore throat could explain this result (26).

A study done by Nkoke et al [28] showed a low level of knowledge of RHD. This study provides important insight into the perception and practices related to sore throat that can be used in the design of awareness activities [27].

Regarding the management of acute pharyngotonsillitis, none of the patients in the first cycle was given the right antibiotic treatment according to the guidelines, and potent advanced generations antibiotics like cefixime and (amoxicillin + clavulanic acid) were prescribed. This practice potentially has serious complications as it may lead to unnecessary antibiotic treatment for viral and GAS pharyngitis and the emergence of antibiotic-resistant organisms like pneumococci [28]. It has been documented in a previous study that sore throat is largely caused by a viral infection, GAS constitutes only 25%; therefore, clinical criteria need to be applied before giving antibiotics [29].

Raising doctors’ awareness regarding the proper management of acute pharyngotonsillitis which was done through group discussion and training sessions resulted in great improvement in the second cycle. This emphasises the importance of conducting training workshops to emergency and outpatient physicians at different levels. The Ministry of Health, as well as professional societies, needs to consolidate these training programs in order to improve the diagnosis and treatment of bacterial pharyngotonsillitis. Educational sessions had an important role in enhancing the level of knowledge about the proper management of pharyngotonsillitis as mentioned by Bhatt et al [27]. A meta-analysis done by Hu et al [31] illustrated the effectiveness of educational sessions in reducing the prescribing of antibiotics for upper respiratory tract infections in children, and this helps in decreasing the inappropriate use of antimicrobial agents [30].

IM benzathine penicillin is the recommended antibiotic in Sudan for the treatment of GAS pharyngotonsillitis as it was proven to be cost-effective with better bactericidal effect than oral drugs which can lead to clinical improvement but do not eradicate the organism. It also decreases the problems related to compliance because it is just a single dose [18,31]. The drug is heavy and painful and occasionally causes allergic reactions hence it needs special administration protocols [18]. Therefore, some health workers and sometimes families are reluctant to use it, as was seen in our study.

Benzathine penicillin availability is an important obstacle to the management of bacterial pharyngitis and ARF, not only in Sudan but also in many other countries [32]. Local and global efforts are needed to improve availability, especially in primary healthcare centers of RHD-endemic countries such as Sudan.

Another problem is that some patients or parents refuse the injectable drugs like IM benzathine penicillin. Good counseling to patients and their parents regarding the importance of this drug and the complications of bacterial pharyngotonsillitis may help solving this problem.

Although not included in the guidelines, in this study complete blood cell count (CBC) for patients helped in establishing the diagnosis of acute bacterial infection as we found that in the first cycle, 75% of patients who were diagnosed with acute bacterial pharyngotonsillitis according to guidelines were having high TWBC and 62.5% had high neutrophils count.

Limitations of the present study include the sample size which was not large, hence the results cannot be generalized. Also, the recommended drug for managing acute bacterial pharyngotonsillitis was not always available.

CONCLUSION

In conclusion, the current practice toward acute pharyngotonsillitis management and diagnosis among paediatric patients is mainly due to a lack of doctors’ knowledge about local guidelines and it can greatly be improved by simple ways of knowledge provision such as posters, lectures and focused group discussions. Those interventions are easy to apply and have a great impact on paediatric health and the prevention of serious devastating sequels such as RHD and the emergence of antibiotic-resistant organisms. Hence, we recommend that more educational sessions to increase doctors’ knowledge about the local guidelines for diagnosing and managing acute pharyngotonsillitis need to be conducted.

We also recommend doing more studies to find out the applicability and importance of simple investigations like CBC and inflammatory markers like CRP and ESR to support the clinical prediction rule regarding the diagnosis of acute pharyngotonsillitis.

Importantly, benzathine penicillin needs to be made available in primary and secondary health facilities. Health workers need to be trained in proper administration of this drug.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

FUNDING

None.

ETHICAL APPROVAL

Ethical approval was obtained from the Paediatric Department, Ribat Teaching Hospital, Khartoum, Sudan. Informed consent was taken from all participants.