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July 14, 2004

Strategies to Diagnose and Treat Group A Streptococcal Pharyngitis

Author Affiliations

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2004;292(2):167. doi:10.1001/jama.292.2.167-a

To the Editor: Dr McIsaac and colleagues1 reported that empirical treatment of adults with high risk of group A streptococcal (GAS) pharyngitis was associated with a higher rate of unnecessary prescriptions than with use of a diagnostic test. We feel that these results cannot be generalized to the population of adults with suspected GAS pharyngitis, as the study's calculated antibiotic prescription rates are derived from a subpopulation of adults with a higher prevalence of GAS pharyngitis. In order to make adequate comparisons between the study's results and the American College of Physicians–American Society of Internal Medicine/American Academy of Family Physicians/US Centers for Disease Control and Prevention (ACP-ASIM/AAFP/CDC) principles of appropriate antibiotic use for acute pharyngitis in adults, we believe that the authors should have also cited our explicit rationale contained in the 2001 CDC principles2 for the 3 options for antibiotic treatment strategies in adults. Based on our assumption of a literature-based 10% prevalence of GAS infection in adult pharyngitis, 11% of adults would receive antibiotics under a test-and-treat strategy, compared with 33% using an empirical strategy. Because about two thirds of US adults who seek care for sore throat/pharyngitis receive antibiotics,3 we believe that the latter strategy would markedly decrease antibiotic use, save on the time and costs of microbiological testing, and reserve treatment for patients with the most severe symptoms.