The public health department of a developing country performs an epidemiologic study to assess the nationwide incidence of upper respiratory infections among children. The data show a high rate of childhood bacterial pharyngitis. Current practice guidelines indicate that a rapid test should be performed in children to identify the presence of bacterial antigens. If this test is negative, a throat culture, the gold standard for definitive diagnosis, is then performed. To offset cost and avoid losing patients to follow-up, the department is considering recommending the empiric use of penicillin for the treatment of suspected bacterial pharyngitis. Which of the following would be expected to decrease after long-term implementation of this guideline?

Question

The public health department of a developing country performs an epidemiologic study to assess the nationwide incidence of upper respiratory infections among children.  The data show a high rate of childhood bacterial pharyngitis.  Current practice guidelines indicate that a rapid test should be performed in children to identify the presence of bacterial antigens.  If this test is negative, a throat culture, the gold standard for definitive diagnosis, is then performed.  To offset cost and avoid losing patients to follow-up, the department is considering recommending the empiric use of penicillin for the treatment of suspected bacterial pharyngitis.  Which of the following would be expected to decrease after long-term implementation of this guideline?

Quizplus · Accepted Answer

11ec160b_3854_1b04_9249_6f9c8d23e2d6_MD0001_00 Early penicillin treatment of group A streptococcal pharyngitis is important for the prevention of acute rheumatic fever (ARF), a major cause of cardiovascular death in many developing nations. ARF primarily affects the heart and central nervous system because host antibodies produced in response to streptococcal antigens cross-react with host antigens in these organs. Chronic cardiac inflammation can progress to rheumatic heart disease, specifically valvular disease. The mitral valve is the most commonly affected and gradually thickens, fibroses, and calcifies, eventually requiring valvotomy or more invasive surgical intervention. Empiric therapy for a condition must be considered in the context of the host characteristics, pre-test probability of the disease, benefits/risks of waiting for a definitive diagnosis, and cost of therapy versus its potential complications. If all cases of acute streptococcal pharyngitis were treated empirically, the incidence of rheumatic heart disease and associated cardiac procedures would likely decrease. (Choice A) Antibiotic use can promote diarrhea by altering the gut microbial milieu. This alteration can lead to overgrowth of Clostridium difficile, a gram-positive bacterium that can cause profuse, watery diarrhea and life-threatening fulminant colitis. Therefore, increasing antibiotic use would likely result in increased diarrheal illness and potential complications. (Choice B) Serum sickness-like reactions are associated with certain infections (eg, hepatitis B) and antibiotics (eg, penicillin). The development of circulating drug-specific immune complexes may cause fever, rash, and arthritis. If penicillin was used more frequently, serum sickness-like reactions would potentially increase, not decrease. (Choice C) Post-streptococcal glomerulonephritis (PSGN) is the most common cause of nephritic syndrome in children worldwide. It is caused by deposition of immune complexes in glomeruli following pharyngitis or skin infections with group A Streptococcus. Although early antibiotics are effective in preventing ARF, they have not been shown to reduce the risk of PSGN. (Choice E) Empiric use of potentially unnecessary antibiotics may cause an increase in antibiotic resistance, thereby increasing the need for broad-spectrum antibiotics. For example, methicillin-resistant Staphylococcus aureus (MRSA) evolved from methicillin-sensitive S aureus via alteration of the protein binding site for beta-lactam antibiotics. As a result, broad-spectrum antibiotics (eg, vancomycin, daptomycin) are required for MRSA infections. Educational objective: Acute rheumatic fever is a complication of untreated group A streptococcal pharyngitis. Rheumatic heart disease is the most common cause of acquired valvular heart disease and cardiovascular death in developing countries. The incidence of acute rheumatic fever and rheumatic heart disease has been reduced in industrialized nations with prompt treatment of streptococcal pharyngitis with penicillin. __________ References: Primary prevention of acute rheumatic fever and rheumatic heart disease with penicillin in South African children with pharyngitis: a cost-effectiveness analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23652737) Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 Update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/22965026) Diagnostic criteria of acute rheumatic fever. (http://www.ncbi.nlm.nih.gov/pubmed/24424191)

The Public Health Department of a Developing Country Performs an Epidemiologic