A case of phlegmonous gastritis after acute pharyngitis

Background: A multicenter audit-and-feedback intervention was conducted to improve management of acute respiratory infections (ARIs) including group A streptococcal (GAS) pharyngitis within 6 VA medical Centers (VAMCs). A relative reduction (24.8%) in azithromycin prescribing after the intervention was observed. Within these facilities during 2015–2018, 2,266 cases of GAS occurred, and susceptibility to erythromycin ranged from 55% to 70%. We evaluated whether prescribing a macrolide for GAS pharyngitis was associated with an increase in outpatient return visits. Methods: A cohort of ambulatory adults treated for GAS pharyngitis (years 2014–2019) at 6 VAMCs was created. Demographic, diagnostic, treatment, and revisit data were extracted from the Corporate Data Warehouse. GAS pharyngitis was defined by an acute pharyngitis diagnostic code combined with a GAS-positive rapid strep test or throat culture ≤3 days of index date. Antibiotic prescriptions were included if filled ≤3 days of index date and were classified as first line (penicillin/amoxicillin), second line (cephalexin/clindamycin), macrolides (azithromycin, clarithromycin, erythromycin), or other (remaining antibiotics). A return visit was defined as a new visit to primary care, urgent care, or the emergency department with a diagnostic code for an ARI ≤30 days from the index visit. Logistic regression was used to adjust for nonantibiotic covariates and to compare treatments. Results are reported as odds ratio (OR ± 95% CI; P value). Results: Of 12,666 patients with a diagnostic code for acute pharyngitis, 2,923 (23.1%) had GAS testing performed. Of those, 582 (19.9%) were GAS-positive and 460 (15.7%) received antibiotics. The mean age was 39.0 years (±SD, 11.7) and 73.7% were male. Antibiotics included penicillins for 363 patients (78.9%), cephalosporins for 21 (4.6%), clindamycin for 32 (7.0%), macrolides for 47 (10.2%), and other for 17 (3.9%). Penicillin allergy was documented in 48 patients (10.5%), and these patients received cephalosporins (18.8%), clindamycin (35.4%), macrolides (41.7%), and other antibiotics (4.2%). Return visits occurred in 47 cases (10.4%). Limited chart review indicated that 6 of 10 macrolide recipients (60.0%) with return visits had recurrence or unresolved symptoms. After adjustment for calendar month and facility, odds of a return visit for treatment with a macrolide relative to penicillins was 2.79 (OR, 1.19; 95% CI, ±6.56; P = .02). The audit-feedback intervention was not associated with ARI-related return visits (OR, 0.53; 95% CI, 0.26–1.06; P = .07). Conclusions: Return visit rates were higher for GAS pharyngitis patients treated with a macrolide than for those treated with penicillins. Macrolides were the most commonly prescribed non-penicillin therapy irrespective of penicillin allergy. Further work is necessary to determine the reason for the increase in return visits.Funding: NoneDisclosures: None

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Evaluation on immediate analgesic efficacy and safety of Kai-Hou-Jian spray (children’s type) in treating sore throat caused by acute pharyngitis and tonsillitis in children: study protocol for a randomized controlled trial

Trials ◽

10.1186/s13063-021-05148-1 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Yan-ning Ma ◽

Cheng-liang Zhong ◽

Si-yuan Hu ◽

Qiu-han Cai ◽

Sheng-xuan Guo

Keyword(s):

Clinical Trial ◽

Sore Throat ◽

Controlled Trial ◽

Analgesic Efficacy ◽

Effective Rate ◽

Efficacy And Safety ◽

Double Blind ◽

Acute Pharyngitis ◽

Randomized Controlled ◽

Parallel Group

Abstract Background Acute pharyngitis and tonsillitis are common respiratory diseases for which children seek medical care. Their main clinical manifestation is sore throat which interferes with patients’ quality of life. However, there is no proven effective or safe method to treat it. It is necessary to find an excellent strategy to reduce sore throat and reduce the burden of acute illness. We designed the randomized controlled trial with the characteristics of traditional Chinese medicine (TCM) to determine the clinical positioning of Kai-Hou-Jian spray (children’s type) (KHJS) through evidence-based research. This trial aims to evaluate the immediate analgesic efficacy of KHJS on sore throat caused by acute pharyngitis and tonsillitis (wind-heat syndrome/heat exuberance in lung and stomach syndrome) in children and to observe its safety. Methods/design This is a prospective, multicenter, randomized, double-blind, parallel-group, placebo-controlled trial. It will include 240 children with acute pharyngitis/tonsillitis from 7 study sites across China. All participants are randomly assigned to two parallel treatment groups, one with KHJS and the other with placebo sprays, for 5 consecutive days. The primary outcome is the time of analgesic onset. Secondary outcomes include duration of analgesic effect, area under time curve of 0–3 h Wong-Baker FACES Pain Rating Scale (WBS) score (AUC0-3 h), rate of analgesic onset, rate of disappearance of sore throat, changes of WBS score (in days), effective rate of pharyngeal signs, and effective rate of TCM syndrome. The incidence of adverse events during the trial is the primary safety outcome. In addition, vital signs and laboratory tests before and after medication are monitored. Discussion To our knowledge, this will be the first clinical trial to explore the immediate analgesic efficacy of a Chinese patent medicine spray for acute pharyngitis/tonsillitis induced sore throat in children in a multicenter, randomized, double-blinded, parallel-group, placebo-controlled manner. Not only might it prove the efficacy and safety of KHJS in the treatment of sore throat caused by acute pharyngitis/tonsillitis in children, but it might also provide evidence for the treatment of acute sore throat with Chinese herbal medicine. Trial registration A multicenter, randomized, double-blind, very low-dose, parallel controlled trial for the immediate analgesic effect and safety of Kai-Hou- Jian spray (children's type) in the treatment of sore throat caused by acute pharyngitis and tonsillitis in children. Chinese Clinical Trial Registry ChiCTR2000031599. Registered on 5 April 2020

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154. Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Adults with Acute Pharyngitis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.199 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S87-S87

Author(s):

Ebbing Lautenbach ◽

Keith W Hamilton ◽

Robert Grundmeier ◽

Melinda M Neuhauser ◽

Lauri Hicks ◽

...

Keyword(s):

Chart Review ◽

Inappropriate Prescribing ◽

Antibiotic Use ◽

University Of Pennsylvania ◽

Antibiotic Prescribing ◽

Acute Pharyngitis ◽

Test Characteristics ◽

Appropriate Prescribing ◽

Concurrent Infections ◽

The Impact

Abstract Background Although most antibiotic use occurs in outpatients, antibiotic stewardship programs (ASPs) have primarily focused on inpatients. A major challenge for outpatient ASPs is lack of accurate and accessible electronic data to target interventions. We developed and validated an electronic algorithm to identify inappropriate antibiotic use for adult outpatients with acute pharyngitis. Methods In the University of Pennsylvania Health System, we used ICD-10 diagnostic codes to identify patient encounters for acute pharyngitis at outpatient practices between 3/15/17 – 3/14/18. Exclusion criteria included immunocompromising conditions, comorbidities, and concurrent infections that might require antibiotic use. We randomly selected 300 eligible subjects. Inappropriate antibiotic use based on chart review served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriate prescribing, choice of antibiotic, and duration included positive streptococcal testing, use of penicillin/amoxicillin (absent b-lactam allergy), and 10 days maximum duration of therapy. Results Of 300 subjects, median age was 42, 75% were female, 64% were seen by internal medicine (vs. family medicine), and 69% were seen by a physician (vs. advanced practice provider). On chart review, 127 (42%) subjects received an antibiotic, of which 29 had a positive streptococcal test and 4 had another appropriate indication. Thus, 74% (94/127) of patients received antibiotics inappropriately. Of the 29 patients who received appropriate prescribing, 27 (93%) received an appropriate antibiotic. Finally, of the 29 patients who were appropriately treated, 29 (100%) received the correct duration. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table. Conclusion Inappropriate antibiotic prescribing for acute pharyngitis is common. An electronic algorithm for identifying inappropriate prescribing, antibiotic choice, and duration is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future work. Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration Disclosures All Authors: No reported disclosures

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Prolonged Myelosuppression due to Progressive Bone Marrow Fibrosis in a Patient with Acute Promyelocytic Leukemia

Case Reports in Hematology ◽

10.1155/2019/1616237 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7

Author(s):

Yuta Inagawa ◽

Yukiko Komeno ◽

Satoshi Saito ◽

Yuji Maenohara ◽

Tetsuro Yamagishi ◽

...

Keyword(s):

Bone Marrow ◽

Acute Promyelocytic Leukemia ◽

Bone Marrow Biopsy ◽

Gastric Fluid ◽

Promyelocytic Leukemia ◽

Consolidation Therapy ◽

Bone Marrow Fibrosis ◽

All Trans Retinoic Acid ◽

Phlegmonous Gastritis ◽

Marrow Fibrosis

A 34-year-old woman was diagnosed with acute promyelocytic leukemia. Chemotherapy was administered following the JALSG APL204 protocol. Induction therapy with all-trans retinoic acid resulted in complete remission on day 49. She developed coccygeal pain from day 18, which spread to the spine and cheekbones and lasted 5 weeks. She had similar bone pain on days 7–10 of the first consolidation therapy and on days 4–12 of the second consolidation therapy. Oral loxoprofen was prescribed for pain relief. On day 33 of the third consolidation, white blood cell and neutrophil counts were 320/μL and 20/μL, respectively. After she developed epigastralgia and hematemesis, she developed septic shock. Gastroendoscopy revealed markedly thickened folds and diffusely damaged mucosa with blood oozing. Computed tomography revealed thickened walls of the antrum and the pylorus. Despite emergency treatments, she died. Bacterial culture of the gastric fluid yielded Enterobacter cloacae and enterococci growth. Collectively, she was diagnosed with phlegmonous gastritis. Retrospective examination of serial bone marrow biopsy specimens demonstrated progressive bone marrow fibrosis, which may have caused prolonged myelosuppression. Thus, evaluation of bone marrow fibrosis by bone marrow biopsy after each treatment cycle might serve as a predictor of persistent myelosuppression induced by chemotherapy.

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Positive Rate of Tests for Group a Streptococcus and Viral Features in Children with Acute Pharyngitis

Children ◽

10.3390/children8070599 ◽

2021 ◽

Vol 8 (7) ◽

pp. 599

Author(s):

Dasom Wi ◽

Soo-Han Choi

Keyword(s):

Laboratory Testing ◽

Older Patients ◽

Group A Streptococcus ◽

Throat Culture ◽

Acute Pharyngitis ◽

Rapid Antigen Detection Test ◽

Positive Rate ◽

Group A ◽

Centor Score ◽

Low Prevalence

Group A streptococcus (GAS) is an important cause of acute pharyngitis. We investigated the positive rate of GAS tests and clinical viral features in children with acute pharyngitis. A retrospective review was conducted for patients <15 years old with both rapid antigen detection test (RADT) and throat culture results. Patients were excluded if they were diagnosed with influenza or had received antibiotics within two weeks before these tests. A total of 377 patients were eligible. The median age of patients was 3.5 years, and 45.4% of total patients were <3 years old. Among all patients, 68.7% had at least one viral feature, and 39% had more than two. The overall positiv rate for GAS was 11.4%. The GAS positive rate was significantly lower in patients <3 years old than in older patients (1.8% vs. 19.4%, p < 0.0001). The overall sensitivity and specificity of RADT were 75.0% (95% CI: 57.8–87.9) and 97.9% (95% CI: 95.8–99.2), respectively. The GAS positive rate was not significantly different between patients with and without viral features (12.4% vs. 9.3%, p = 0.4854). In patients aged 3–14 years, the GAS positive rate was not associated with the modified Centor score or the frequency of clinical viral features. Despite a low prevalence of GAS pharyngitis, testing for GAS was frequently performed in children <3 years old in this study. Appropriate use of laboratory testing for GAS pharyngitis and judicious prescription of antibiotics were imperative.

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