Clinical Therapeutics/Volume ], Number ], 2017

Choosing Wisely: The Top-5 Recommendations

from the Italian Panel of the National Guidelines for
the Management of Acute Pharyngitis in Children
Elena Chiappini, MD, PhD1; Barbara Bortone, MD1; Giuseppe Di Mauro, MD2;
Susanna Esposito, MD3; Luisa Galli, MD1; Massimo Landi, MD4; Andrea Novelli, MD5;
Paola Marchisio, MD3; Gian Luigi Marseglia, MD6; Nicola Principi, MD3; and
Maurizio de Martino, MD1 for the Italian Panel on the Management of Pharyngitis in
Children*
1
Anna Meyer Childrens University Hospital, Department of Health Sciences, Section of Paediatrics,
University of Florence, Florence, Italy; 2primary care pediatrician, Caserta, Italy; 3Department of
Pediatrics, Santa Maria della Misericordia Hospital, University of Perugia, Italy; 4primary care
pediatrician, Turin, Italy; 5Department of Health Sciences, Section of Pharmacology, University of Florence,
Florence, Italy; and 6Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of
Pavia, Pavia, Italy

ABSTRACT Implications: This top-5 list can be a novel tool to

Purpose: With the aim to reduce waste in the health
care system and avoid risks associated with unneces-
sary treatment, the Italian Panel of the National
Guidelines for the Management of Acute Pharyngitis
in Children joined the Choosing Wisely initiative.
Methods: An ad hoc Choosing Wisely task force
was selected to develop a candidate list of items for the
top-5 list on pharyngitis medicine. Through a process
of literature review and consensus, the nal list of 5
items was chosen. Drafted recommendations were
formulated and then reviewed by the task force
members until a nal consensus was reached.
Findings: The 5 recommendations approved are:
blood exams should not be performed; antibiotics
should not be administrated unless microbiologic
conrmation of streptococcal infection has been car-
ried out; if a throat culture is performed, susceptibility
tests on isolates should not be executed; antibiotic
course should not be shortened; because penicillin V is
not available in Italy, amoxicillin (50 mg/kg/d in 23
doses orally) for 10 days is the rst choice treatment;
and steroids should not be administered for the risk of
masking possible underlying severe condition.
spread the key messages of guidelines and to avoid
unnecessary diagnostic procedures, and to promote a
rational use of antibiotics in children. (Clin Ther.
2017;]:]]]]]]) & 2017 Elsevier HS Journals, Inc. All
rights reserved.
Key words: antibiotics, children, choosing wisely,
pharyngitis, streptococcal infections.
INTRODUCTION
Some estimates suggest that as much as 30% of health
care spending is wasted because of physician decisions
driven by not-up-to-date medical knowledge or by an
inclination to satisfy patient requests.1 Choosing
Wisely is a project originally developed in Canada
during 2012 that aims to reduce prescription of
unnecessary tests and treatments that not only waste
health care resources, but also place patients at risk of
harm.2 Subsequently, several Choosing Wisely
campaigns have been conducted by different medical
societies or government organizations worldwide,
developing numerous top-5 lists of recommendations

Accepted for publication January 11, 2017.

http://dx.doi.org/10.1016/j.clinthera.2017.01.021
*
Members of the Italian Panel on the Management of 0149-2918/$ - see front matter
Pharyngitis in Children are listed in the Acknowledgments. & 2017 Elsevier HS Journals, Inc. All rights reserved.

] 2017 1
 Clinical Therapeutics
on various themes. These projects promote conversa-
tion between physicians and patients to transmit
transparent and credible information to patients, the
message that doing more does not always mean doing
better, and in some cases unnecessary diagnostic
procedures and therapies can be harmful for patients.2
During February 2013, the American Academy of
Pediatrics issued a top-10 list of recommendations to be
adopted in pediatric care.3 These statements dealt with
various pediatric elds such as traumatology and
allergology other than infectious diseases. Notably, the
rst recommendation of the American Academy of
Pediatrics discourages the use of antibiotics in cases
of apparent viral respiratory infections (ie, most cases of
pharyngitis, and almost all cases of bronchitis and
bronchiolitis).3 In a recent review,4 it was observed that
628 recommendations from 113 medical societies have
been published.4 Fifty-one (8%) of the recommendations
deal with infectious diseases. The unnecessary use of
antibiotics in upper respiratory tract infections and in
asymptomatic bacteriuria was the most frequent recom-
mendation of several societies from different countries.4
On the other hand, to date no specic Choosing Wisely
campaign regarding the management of acute pharyngitis
has been issued.
The Italian Panel of the National Guidelines for the
Management of Acute Pharyngitis in Children
decided to contribute to the Italian Choosing
Wisely campaign by developing a top-5 list regarding
the management of acute pharyngitis with the aim to
spread the recommendation of the previous national
guideline issued by the Italian Health Institute.5,6
METHODS
The director of the Italian Panel on the Management of
Pharyngitis in Children selected an ad hoc task force to
identify, through a review of literature and consensus, the
5 items for the list of recommendations. Once consent
was obtained on the nal list of 5 items, the statements
were formulated. Drafted recommendations were formu-
lated and then reviewed and discussed among the task
force members until nal consensus was reached. Follow-
ing the American Board of Internal Medicine (ABIM)
guideline recommendations, each item is presented as a
single, action-oriented sentence no more than 15 words
long. Evidentiary statements of fewer than 75 words
follow each recommendation to give a brief overview of
the evidence behind the recommendation.1
2 Volume ] Number ]
RESULTS
The top-5 list is shown in Table I. In particular, attention
has been paid to discourage the use of unnecessary
diagnostic tests (eg, antistreptolysin O titer, anti-
deoxyribonuclease (anti-DNA-se) antibodies, other
blood tests, and antibiotic susceptibility tests on isolates
from throat cultures).6 The only necessary diagnostic
investigation to carry out in accordance with the
guidelines recommendations is a microbiology test (eg,
rapid antigen diagnostic test [RADT] or throat culture).6
This allows for the diagnosis of an eventual streptococcal
pharyngitis and the selection of the minority of children
who actually need antibiotic treatment. In particular, the
Italian guideline suggests the use of RADT rather than
throat culture.6 Indeed, throat culture represents the gold
standard for the diagnosis of streptococcal pharyngitis,
but has some disadvantages such as high cost, outcome
not immediately available, and the need to send the swab
to a laboratory. Moreover, the current RADTs have
satisfactory sensitivity and specicity. For these reasons,
backup culture in children with a negative RADT result
is not recommended.6 It should be remembered that
RADT should be performed by trained personnel and
the child should present with a history and signs or
symptoms suggestive of streptococcal pharyngitis. RADT
is not recommended in children with a McIsaac score of
0 or 1 with Z2 signs or symptoms suggestive of viral
infection to avoid treatment in healthy carriers. The rst-
line recommended therapy is amoxicillin (50 mg/kg/d in
2-3 doses orally) for 10 days because penicillin V is not
available in Italy.5,6 According to literature reports, only
10-day therapy is associated with an effective reduction
in the risk of rheumatic disease; therefore, it is not
prudent to shorten the duration of treatment. Alterna-
tively, only in noncompliant patients, intramuscular
benzathine penicillin may be administered (recom-
mended dose: 600,000 IU in children weighing o30
kg or 1,200,000 IU in children weighing Z30 kg). It is
important not to administer steroids, which can mask
possible underlying severe conditions.7
DISCUSSION
Choosing Wisely campaigns have been demonstrated
to be an effective method to disseminate key guideline
messages in a direct and easily understandable way.8
Therefore, the panel joined the Choosing Wisely
initiative with the rst goal of rationalizing the
prescription of antibiotics for children with acute
 E. Chiappini et al.

Table I. Top-5 recommendations for the management of acute pharyngitis in children.

1 Blood exams should not be performed

Blood tests, including inammatory markers, are not useful in differentiating bacterial from viral pharyngitis
because they can also be increased in some viral infections. Antistreptolysin O titer and anti-DNAse
antibodies are useful for the diagnosis of poststreptococcal complications, such as rheumatic fever and
glomerularnephritis, both occurring some weeks after the acute streptococcal infection. They are not of
help for the diagnosis at the time of an episode of acute pharyngitis
2 Antibiotics should not be administered unless microbiologic conrmation of streptococcal infection has been
carried out
Most pharyngitis cases are of viral origin and do not require antibiotic therapy. It is not possible to distinguish
bacterial from viral infection only on a clinical basis. Therefore, a rapid test or throat culture is necessary to
select children with streptococcal infection. Microbiologic tests should be carried out only in children with
suggestive symptoms, in accordance with the guideline recommendations, to avoid the treatment of healthy
carriers. Do not repeat test at treatment completion
3 If throat culture is performed, susceptibility tests on isolates should not be executed
To date, streptococcal isolates are university sensitive to penicillin and amoxicillin. Susceptibility tests increase
costs without providing benets in terms of choice of antibiotic therapy
4 Antibiotic course should not be shortened
The recommended rst choice antibiotic therapy is amoxicillin 50 mg/kg divided into 2-3 administrations for
10 d. Only a 10-d therapy is associated with effective reduction in the risk of rheumatic disease. Only in
cases with poor compliance should intramuscular benzathine penicillin is recommended
5 Steroids should not be administered
The administration of steroids may mask signs or symptoms of other possible associated diseases and could
lead to a delay in diagnosis of medical conditions that, although rare, can be severe, such as lymphomas or
other malignancies

pharyngitis. In pediatric care, most prescriptions for CONCLUSIONS

antibiotic agents address upper respiratory tract
infections. For example, in the United States, for an
expected prevalence of bacterial infections in 27.4% of
cases, antibiotics are prescribed in 56.9% of upper
respiratory infections. In other words, as many as 11.4
million prescriptions for antibiotic agents may
potentially be avoidable.9 Several studies demonstrate
that educational and antimicrobial stewardship
programs change attitudes regarding prescription of
these drugs in outpatient and inpatient care and limit
the spread of resistant bacteria strains.10,11 As with
antibiotics, inappropriate use of steroids can be harmful
as well as expensive.7 It has been demonstrated that
steroids may mask signs or symptoms of underlying
severe diseases such as lymphomas or other
malignancies, potentially leading to a delay in
diagnosis.7 Considering the availability of other
analgesics, such as acetaminophen and ibuprofen, the
use of steroids for pharyngitis in children should be
avoided.
This top-5 list can be a novel tool to spread the key
messages of guidelines and to avoid unnecessary
diagnostic procedures. In addition it can promote
rational use of antibiotics in children.
ACKNOWLEDGMENTS
Italian Panel on the Management of Pharyngitis in
Children includes Paolo Becherucci, Firenze; Giovanni
Felisati, Milano; Nicola Principi, Milano; Luisa Bellussi,
Siena; Filippo Festini, Firenze; Salvatore Puglisi, Catania;
Francesca Bonsignori, Pediatra, Firenze; Renato Maria
Gaini, Monza; Maria Gabriella Rugiu, Udine; Angelo
Camaioni, Roma; Luisa Galli Firenze; Agostino Serra,
Catania; Elena Chiappini, Firenze; Massimo Landi, Tor-
ino; Andrea Novelli, Firenze, Annamaria Speciale, Cata-
nia; Marina De Gaudio, Firenze; Luigi Maiolino, Catania;
Pier-Angelo Tovo, Torino; Maurizio de Martino, Firenze,
Nicola Mansi, Napoli; Pasquale Tulimiero, Firenze,
Salvatore De Masi, Firenze; Giuseppe Mele, Lecce;

] 2017 3
 Clinical Therapeutics

Attilio Varricchio, Napoli; Luciana de Simone, Firenze;
Paola Marchisio, Milano; Elisabetta Venturini, Firenze;
Giuseppe Di Mauro, Caserta; and Gian Luigi Marseglia,
Pavia. All the authors contributed equally in the literature
search, study design, data collection and data
interpretation. Elena Chiappini and Barbara Bortone
drafted the initial manuscript. All the authors approved
the nal manuscript as submitted and agree to be
accountable for all aspects of the work.
CONFLICTS OF INTEREST
The authors have indicated that they have no conicts
of interest regarding the content of this article.
REFERENCES
1. Wolfson D, Santa J, Slass L. Engaging physicians and
consumers in conversations about treatment overuse and
waste: a short history of the choosing wisely campaign.
Acad Med. 2014;89:990995.
2. Cassel CK, Guest JA. Choosing Wisely Helping Physicians
and Patients Make Smart Decisions About Their Care.
JAMA. 2012;307:18011802.
3. American Academy of Pediatrics. Ten Things Physicians
and Patients Should Question. website: http://www.choo
singwisely.org/societies/american-academy-of-pediatrics.
Last accessed October 10, 2016.
4. Jung N, Lehmann C, Ftkenheuer G. The Choosing Wisely:
initiative in infectious diseases. Infection. 2016;44:283290.
5. Chiappini E, Mazzantini R, Bruzzese E, et al. Italian
Society of Preventive and Social Pediatrics. Rational use
of antibiotics for the management of children's respira-
tory tract infections in the ambulatory setting: an
evidence-based consensus by the Italian Society of
Preventive and Social Pediatrics. Paediatr Respir Rev.
2014;15:231236.
6. Chiappini E, Principi N, Mansi N, et al. Italian Panel on
the Management of Pharyngitis in Children. Management
of acute pharyngitis in children: summary of the Italian
National Institute of Health guidelines. Clin Ther.
2012;34:14421458.
7. Sadowitz PD, Page NE, Crowley K. Adverse effects of
steroid therapy in children with pharyngitis with unsus-
pected malignancy. Pediatr Emerg Care. 2012;28:807809.
8. Morden NE 1, Colla CH, Sequist TD, Rosenthal MB.
Choosing wiselythe politics and economics of labeling
low-value services. N Engl J Med. 2014:370589370592.
9. de Bie S, Kaguelidou F, Verhamme KM, et al. ARPEC
study. Using Prescription Patterns in Primary Care to
Derive New Quality Indicators for Childhood Community
Antibiotic Prescribing. Pediatr Infect Dis J. 2016. Sep 12.
[Epub ahead of print].
10. Principi N, Esposito S. Antimicrobial stewardship in
paediatrics. BMC Infect Dis. 2016;16:424.
11. European Centre for Disease Prevention and Control.
Antimicrobial resistance interactive database (EARS-
Net). Website: http://ecdc.europa.eu/en/healthtopics/
antimicrobial-resistance-and-consumption/antimicrobial_
resistance/database/Pages/database.aspx. Last accessed
October 10, 2016.

Address correspondence to: Elena Chiappini, MD, PhD, Department of

Health Sciences, Anna Meyer Childrens University Hospital, University of
Florence, Viale Pieraccini, 24, Florence, Italy. E-mail: elena.chiappini@
uni.it

4 Volume ] Number ]