Clinical management and patient persistence with antibiotic course in suspected group A streptococcal pharyngitis for primary prevention of rheumatic fever: the perspective from a New Zealand emergency department.

AIM: Rates of acute rheumatic fever in the Northland region are historically among the highest in New Zealand, impacting disproportionately on Maori children and youth. The primary aim of this study was to determine patient persistence to antibiotic treatment for group A streptococcus (GAS) pharyngitis in patients presenting with sore throat to the Whangarei Hospital Emergency Department. Secondarily, this study sought to determine prescriber adherence to the national antibiotic guideline for sore throat management. METHOD: A retrospective audit of patients presenting to ED with presumed GAS pharyngitis between 1 May 2016 and 31 August 2016 was carried out. Data on patient demographics, clinical examination findings, investigations and antibiotic prescription were extracted from electronic medical records. Patients were contacted and after obtaining consent, were asked about their antibiotic treatment using a standardised telephone interview script. RESULTS: The patient population audited reflects those at high risk for acute rheumatic fever. All patients were discharged on the recommended medication, but only 82.7% (62/75) received the correct length (10 days) of oral antibiotics. Of the total of 75 patients audited, 61 (81%) had a swab taken and 41% (25/61) of these were confirmed positive for GAS. Patients were either advised to commence medication without waiting for a swab result (96%, 72/75) or delay treatment and commence only if no improvement in symptoms (4%, 3/75). Of those advised to commence medication immediately, 94% (67/72) obtained their medication from a community pharmacy. Three patients were advised to stop treatment after confirmation of a negative result. Of those patients assessable for medication persistence (n=65), 73.8% (48/65) of patients were compliant in completing the full course of antibiotic therapy. CONCLUSION: This is the first study to assess patient persistence to an antibiotic course for GAS after presentation at an emergency department in Northland and possibly New Zealand. The results indicate a relatively high persistence rate with oral antibiotic treatment by patients treated for suspected GAS pharyngitis. An important finding is that community pharmacy dispensing does not appear to be a major barrier to patients acquiring medications. Additionally, the study shows low levels of follow up of patients with negative throat swab results, resulting in these patients completing the course of antibiotics unnecessarily.

Necrotizing fasciitis due to Vibrio parahaemolyticus.

A report of a fatal case of necrotizing fasciitis of the leg due to Vibrio parahaemolyticus infection. This organism frequently causes minor infections in seawater-exposed wounds. In this case the patient died due to fulminant sepsis caused by necrotizing fasciitis, despite surgical debridement. This case serves as a reminder for targeted antibiotic coverage for Vibrio in any serious saltwater-related infection, and as an illustration of the rapid and severe systemic toxicity associated with Vibrio parahaemolyticus necrotizing fasciitis, even in the setting of minor initial skin findings.