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Toronto Notes 2019 Complementary and Alternative Medicine
Table 24. Modified Centor Score: Approach to Diagnosis and Management of GABHS
Family Medicine FM47
POINTS
Cough absent? 1
History of fever >38oC? 1
Tonsillar exudate? 1
Swollen, tender anterior nodes? 1
Age 3-14 1
Age 15-44 0
Age >45 –1
In communities with moderate levels of strep infection (10-20% of sore throats):
Score
Chance patient has strep Suggested action
0 1
1-2.5% 5-10% NO culture or antibiotic
2 3
11-17% 28-35%
Culture all, treat with antibiotics only if culture is positive
4 or more
51-53%
Culture all, treat with antibiotics on clinical grounds1, discontinue antibiotics if culture comes back negative
1Clinical grounds include a high fever or other indicators that the patient is clinically unwell and is presenting early in the course of the illness Limitations: *This score is not applicable to patients <3 yr of age
*If an outbreak or epidemic of illness caused by GABHS is occuring in any community, the score is invalid and should not be used Adapted from: Centor RM, et al. Med Decis Making 1981;1:239-46; McIssac WI, et al. CMAJ 1998;158:75-83
Management
• viralpharyngitis
■ antibiotics not indicated
■ symptomatic therapy: acetaminophen/NSAIDs for fever and muscle aches, decongestants
• GABHS
■ antibiotic treatment decreases severity and duration of symptoms, risk of transmission (after 24 h of
treatment), and risk of rheumatic fever and suppurative complications
■ incidence of glomerulonephritis is not decreased with antibiotic treatment
■ no increased incidence of rheumatic fever with 48 h delay in antibiotic treatment; if possible, delay
antibiotic treatment until culture confirms diagnosis
■ routine F/U and/or post-treatment throat cultures are not required for most patients
■ F/U throat culture only recommended for: patients with history of rheumatic fever, patients of
family member(s) with history of acute rheumatic fever, suspected streptococcal carrier • infectiousmononucleosis(EBV)
■ self-limiting course; antibiotics are not indicated
■ symptomatic treatment: acetaminophen/NSAIDs for fever, pharyngitis, malaise
■ avoid heavy physical activity and contact sports for at least one month or until splenomegaly
resolves because of risk of splenic rupture
■ if acute airway obstruction, give corticosteroids and consult ENT
Complementary and Alternative Medicine
Epidemiology
• 50-75%ofCanadiansreportsomeuseofCAMovertheirlifetime,andonlyhalfwilldisclosethisuseto their physician
• useishighestinWesternprovincesandlowestinAtlanticprovinces
• morelikelytobeusedbyyoungerpatientsandthosewithhighereducationandincome
• examples:chiropractic,acupuncture,massage,naturopathy,homeopathy,traditionalChinesemedicine,
craniosacral therapy, osteopathy
Herbal Products
• over50%ofCanadiansusenaturalhealthproducts(NHPs)
• mostcommonlyusedincludeechinacea,ginseng,ginkgo,garlic,St.John’swort,andsoy
• relativelyfewherbalproductshavebeenshowntobeeffectiveinclinicaltrials
• manypatientsbelieveherbalproductsareinherentlysafeandareunawareofpotentialsideeffectsand
interactions with conventional medicines
• all NHPs must be regulated under The Natural Health Products Regulations as of January 1, 2004,
including herbal remedies, homeopathic medicines, vitamins, minerals, traditional medicines,
probiotics, amino acids, and essential fatty acids (e.g. omega-3)
• alwaysaskpatientswhethertheyaretakinganyherbalproduct,herbalsupplement,orothernatural
remedy. Further questions may include:
■ Are you taking any prescription or non-prescription medications for the same purpose as the herbal
product?
■ Are you allergic to any plant products? ■ Are you pregnant or breastfeeding?
Most Common Uses of CAM
• Back/neck problems
• Gynecological problems
• Anxiety
• Headaches
• Digestive problems
• Chronic fatigue syndromes
• informationresources:NationalCentreforCAM(www.nccam.nih.gov),HealthCanadawebsite