Original Article
Association between rapid antigen detection tests and antibiotics for acute pharyngitis in Japan: A retrospective observational study

https://doi.org/10.1016/j.jiac.2018.12.005Get rights and content

Abstract

The application and clinical impact of rapid antigen detection test (RADT) in the treatment of acute pharyngitis is unknown in Japan. We aimed to examine the proportions of RADT usage to identify Group A β-hemolytic Streptococcus (GAS) in outpatients with acute pharyngitis and evaluate the association between RADT and antibiotic treatment. We analyzed health insurance claims data from 2013 to 2015. Logistic regression models were used to analyze associated factors with RADT, overall antibiotic prescription, or penicillin use. We analyzed 1.27 million outpatient visits with acute pharyngitis, in which antibiotics were prescribed in 59.3% of visits. Of the total visits, 5.6% of patients received RADT, and 10.8% of the antibiotics were penicillin. Penicillin selection rates were higher in cases with RADT (25.4%) than those without RADT (9.7%). Compared to large-scale facilities, antibiotic prescription rates were higher in physicians' offices. For factor analysis, age (3–15 years), diagnosis code (streptococcal pharyngitis), size of the medical facility (large-scale hospitals), and physician's specialty (pediatrics) were associated with RADT use. Penicillin selection rate increased with RADT implementation (25.4% vs. 9.7%: adjusted odds ratio 1.55; 95% CI, 1.50–1.60). At 63% of the facilities, the RADT implementation rate was <5% of acute pharyngitis visits prescribed antibiotics. In conclusion, the proportion of RADT usage for outpatients with acute pharyngitis was low in Japan. With appropriate indication and evaluation, we expect that more utilization of RADT can help promote antimicrobial stewardship for outpatients with acute pharyngitis by prompting penicillin therapy. Further investigation with detailed clinical data are warranted.

Introduction

Acute pharyngitis is one of the most common reasons for visits to primary care physicians, for which antibiotics are frequently prescribed [1]. However, most cases are caused by viruses, such as adenovirus, influenza virus, and enterovirus [2], [3], which are self-limiting and usually do not require any antibiotic therapy. Group A β-hemolytic Streptococcus (GAS) is the most frequent bacterial pathogen of acute pharyngitis and requires antibiotic treatment for the prevention of sequelae such as acute rheumatic fever and peri-tonsillar abscess [4], [5], [6], [7], [8]. However, GAS pharyngitis accounts for only one-fourth of pediatric pharyngitis cases and approximately 10% of adult cases [2], [3]; furthermore, 41.6%–68% of outpatients with acute pharyngitis undergo unnecessary antibiotic administration [9], [10], [11], [12].

For appropriate treatment of GAS pharyngitis, rapid and accurate diagnosis is expected [4], [7]. It is difficult to differentiate between bacterial and viral pharyngitis using only clinical findings. To increase diagnostic accuracy, clinical scoring methods, such as the Centor criteria [13] and McIsaac criteria [14], have been developed. However, positive predictive values of the Centor score of 1, 2, 3, and 4 were 6.5%, 15%, 32%, and 56%, respectively [13]. A recent large-scale validation study reported that the accuracy of GAS pharyngitis in patients with a full score (4 scores) was 68% among children aged 3–14 years and approximately 60% in those aged ≥15 years [15]. Current guidelines recommend that patients with Centor criteria scores ≤2 do not need further examination for GAS infection [5], [6]. Therefore, the clinical scoring approach may be useful to exclude pharyngitis other than GAS pharyngitis. However, the scoring method may potentially lead to over-diagnosis, which in turn may facilitate unnecessary antibiotic prescription.

Previous literature has reported that a diagnostic strategy based on an antigen test or bacterial culture, rather than clinical scoring, could reduce antibiotic prescribing [16], [17], [18], [19], [20], [21]. A rapid antigen detection test (RADT) can provide a quick result with high accuracy for GAS pharyngitis, which potentially promotes outpatient antimicrobial stewardship. However, other organisms such as Group C/G β-hemolytic Streptococcus or Fusobacterium necrophorum are known to be common pathogens of acute pharyngitis [22], and the use of RADT may cause physicians to overlook cases of bacterial pharyngitis to be treated by antibiotics. Based on this, currently, there is no complete consensus regarding antibiotic treatment based on the clinical score and implementation of RADT among clinical guidelines or scientific societies [4], [5], [6], [23], [24].

In Japan, the clinical guidelines for antimicrobial stewardship were published in 2017 [25] and recommend the active use of RADT for the accurate diagnosis of pharyngitis. However, the clinical use or impact of RADT in Japanese outpatient settings has yet to be exhaustively uncovered. We aimed to clarify the implementation rate of RADT in outpatients with acute pharyngitis and its influence on antibiotic prescribing, associated factors for RADT use and antibiotic prescribing.

Section snippets

Data source

For this study, we used data from the Japan Medical Data Center (JMDC) claims database [26]. This longitudinal database contains anonymized health insurance claims data (inpatient, outpatient, and pharmacy) of over 4 million people, which corresponds to approximately 3% of the entire Japanese population. The JMDC is widely used for healthcare research and has been cited in peer-reviewed journals across a broad range of healthcare topics [27], [28]. The JMDC database was suitable for use in our

Results

We analyzed 1.27 million outpatient visits with acute pharyngitis from 2013 to 2015. The patients visited centers for general internal medicine (50.1%), pediatrics (36.5%), otorhinolaryngology (4.4%), and other specialties (8.9%). In-hour visits accounted for 81.9% of the cases. Of the total visits, 5.6% patients underwent RADT, and 59.3% (751,195 visits) were prescribed with antibiotics, among which penicillin accounted for 10.8% (81,494 visits). RADT implementation rates among patients given

Discussion

In this study, we demonstrated the implementation rates and associated factors for RADT, as well as antibiotic prescribing for outpatients with acute pharyngitis, using health insurance claims data between 2013 and 2015. Of the 1.27 million visits, only 5.6% of the outpatients with acute pharyngitis were examined using RADT. By age group, the RADT implementation rate was the highest among patients aged 6–15 years (11.1%), followed by patients aged 3–5 years (10.2%). Large-scale medical

Conclusion

The present study demonstrated that RADT use for the diagnosis of acute pharyngitis was less common in Japan. Our data suggested that implementation of RADT may not contribute in decreasing antimicrobial prescribing; however, it may optimize antimicrobial therapy, i.e., prompting penicillin treatment rather than treatment with other antibiotics, by helping to identify the etiology of infections. Overuse of broad-spectrum antibiotics increases antimicrobial resistance and possibly exposes

Conflicts of interest

None.

References (33)

  • A.M. Harris et al.

    Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the american college of physicians and the centers for disease control and prevention

    Ann Intern Med

    (2016)
  • A. Spinks et al.

    Antibiotics for sore throat

    Cochrane Database Syst Rev

    (2013)
  • J.L. Schroeck et al.

    Factors associated with antibiotic misuse in outpatient treatment for upper respiratory tract infections

    Antimicrob Agents Chemother

    (2015)
  • J.A. Linder et al.

    Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999

    J Am Med Assoc

    (2001)
  • G.N. Nakhoul et al.

    Management of adults with acute streptococcal pharyngitis: minimal value for backup strep testing and overuse of antibiotics

    J Gen Intern Med

    (2013)
  • R.M. Centor et al.

    The diagnosis of strep throat in adults in the emergency room

    Med Decis Making

    (1981)
  • Cited by (0)

    All authors meet the ICMJE authorship criteria.

    View full text