What is the FeverPAIN (Fever, Purulent tonsils, Antimicrobial use, Infectious mononucleosis, and Necrotizing ulcerative tonsillitis) scoring for acute pharyngitis?

From the Guidelines

The FeverPAIN score is not the recommended scoring system for assessing the likelihood of streptococcal infection in patients with sore throat, instead, the McIsaac score is a more appropriate tool, which considers factors such as temperature, absence of cough, tender anterior cervical adenopathy, tonsillar swelling/exudate, and age. The McIsaac score is a clinical decision tool used to assess the likelihood of streptococcal infection in patients with sore throat and guide antibiotic treatment decisions. It consists of criteria such as temperature ≥ 38 °C, absence of cough, tender anterior cervical adenopathy, tonsillar swelling/exudate, and age < 15 years, with points assigned for each criterion, and age ≥ 45 years subtracting a point 1. Patients with a total score of 1 or less have a low risk of streptococcal infection and generally don't need antibiotics, those with a score of 2-3 have an intermediate risk and may benefit from throat culture or rapid antigen detection test, and patients with a score of 4 or more have a high likelihood of streptococcal infection and should receive immediate antibiotics, typically penicillin V 500mg four times daily for 5-10 days (or clarithromycin 250mg twice daily for 5 days if penicillin-allergic) 2. The McIsaac score helps reduce unnecessary antibiotic use while ensuring appropriate treatment for those most likely to benefit, as streptococcal pharyngitis can lead to complications like peritonsillar abscess or rheumatic fever if untreated in high-risk cases.

Some key points to consider when using the McIsaac score include:

• The score is based on clinical presentation and does not require laboratory confirmation, but laboratory testing may be necessary to confirm the diagnosis in some cases 3
• The score is not perfect and may not accurately predict the likelihood of streptococcal infection in all cases, but it is a useful tool to guide clinical decision-making 4
• Antibiotic treatment should be reserved for patients with a high likelihood of streptococcal infection, as unnecessary antibiotic use can contribute to antimicrobial resistance and other adverse effects 2

In terms of specific treatment recommendations, the Infectious Diseases Society of America (IDSA) guidelines recommend penicillin V or amoxicillin as first-line treatment for streptococcal pharyngitis, with alternative options such as cephalexin, cefadroxil, clindamycin, azithromycin, or clarithromycin for patients with penicillin allergy 2. The guidelines also emphasize the importance of accurate diagnosis and appropriate treatment to prevent complications and reduce the risk of antimicrobial resistance.

Overall, the McIsaac score is a useful tool for assessing the likelihood of streptococcal infection in patients with sore throat and guiding antibiotic treatment decisions, and should be used in conjunction with clinical judgment and laboratory testing as needed to ensure appropriate treatment and prevent complications.

From the Research

FeverPAIN Scoring for Sore Throat

• The FeverPAIN score is a clinical prediction rule used to guide decision making in patients with sore throat, as recommended by the National Institute for Health and Care Excellence (NICE) 5.
• The score is used to identify patients who are likely to have a bacterial throat infection, such as Group A beta-hemolytic streptococcal (GABHS) pharyngitis 6, 7.
• A FeverPAIN score of 2 or 3 is often used as a threshold to order a rapid antigen detection test to diagnose GABHS pharyngitis 6.
• However, the diagnostic accuracy of the FeverPAIN score has been found to be poor, with an area under the receiver operating characteristics (ROC) curve of 0.59 5.
• Higher FeverPAIN scores are associated with increased delayed antibiotic prescriptions, but the score does not provide a reliable way of diagnosing streptococcal throat infection 5.

Comparison with Other Scoring Systems

• The FeverPAIN score has been compared with other clinical prediction rules, such as the Centor score and the McIsaac score 8, 5.
• The McIsaac score has been found to have similar diagnostic accuracy to the FeverPAIN score, with 50-68% of patients with a McIsaac score of 4 or 5 having a positive molecular point-of-care test result 8.
• The Centor score has been found to have slightly better diagnostic accuracy than the FeverPAIN score, with an area under the ROC curve of 0.62 5.

Clinical Implications

• The FeverPAIN score can be used as a tool to guide decision making in patients with sore throat, but it should not be relied upon as the sole means of diagnosis 5.
• A thorough physical examination and patient history should be completed before using the FeverPAIN score or other clinical prediction rules 9.
• Antibiotic treatment should be guided by the results of diagnostic tests, such as rapid antigen detection tests or throat cultures, rather than solely on the basis of the FeverPAIN score or other clinical prediction rules 6, 7.