On twitter this week, several British tweeters discussed whether they should use the FeverPAIN score or the Centor score.  Obviously I have a bias here, but I will try to discuss this issue dispassionately.

So I downloaded the PRISM study, where the authors proposed FeverPAIN.  The goal of FeverPAIN is to increase the patient cohort not needing testing or antibiotics.  As I studied FeverPAIN I found one important advance, but another point of naïveté.

To frame the discussion, the FeverPAIN study took all patients >3 years with sore throats.  They used positive testing for group A, C or G beta hemolytic streptococci as their dichotomous outcome.  They developed a 5 point scale (1 point of each):

Contrast this with the Centor score (again 1 point each):

My first quick impression is that the 2 scores are measuring the same concepts.  Bacterial infections – both group A and group C/G streptococci and (in our recent study) Fusobacterium necrophorum cause an inflammatory response (exudates, swelling, adenopathy), a fever response and a lack of a viral response (lack of cough or coryza).  Thus the two scores will have a very high correlation when you study the components.

FeverPAIN includes an interesting variable – symptom onset at 3 days or less.  As one studies pharyngitis, one notes that acute pharyngitis needs a very careful definition that includes short symptom onset.  I like this inclusion, but caution against disregarding patients with longer symptom duration.  If the patient has worsening symptoms past 3 days, they no longer have acute pharyngitis, but rather need a careful evaluation for either suppurative complications (peritonsillar abscess or Lemierre syndrome) or one should consider significant viral infections in adults – infectious mononucleosis and acute HIV.

The other problem that I have with the FeverPAIN analysis is the lack of distinction between preadolescents and adolescent/young adults.  We have written about this problem, both in MEDRANTS and in this article – Adolescent Pharyngitis: A Review of Bacterial Causes

The streptococcal carrier rates for pre-adolescents are MUCH higher than for adolescents and young adults.  In several studies in which I participated, adolescents and young adults had carrier rates around 1-2%.  This age groups also has GAS less commonly, GC/GS more commonly, and Fusobacterium necrophorum much more commonly.

So what should we do in 2017.  I would suggest to the FeverPAIN authors that they reanalyze their data using an age cutoff of approximately 14 or 15.  I suspect they will find very different findings in the pre-adolescent and older age cohorts.

We should pay great attention to the symptom onset as a criteria for even considering the patient has acute pharyngitis.  If the patient presents at 4 days or later, we should likely not use an algorithm and scoring rule, but rather focus on the clinical course and worry about a broader differential.

We should also diagnose and treat pre-adolescents differently from adolescents/young adults.  The older patients have more severe symptoms and more often develop suppurative complications.

With either scoring system, low scores likely allow us to avoid antibiotics or testing.  But using a score without understanding a larger differential diagnosis in patients with persistent or especially worsening symptoms can result in serious diagnostic errors.