咽痛治疗和扁桃体切除术适应证【美国】

Scottish Intercollegiate Guidelines Network Part of NHS Quality Improvement Scotland SIGN Management of sore throat and indications for tonsillectomy A national clinical guideline April 2010 117 KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1 - Meta-analyses, systematic reviews, or RCTs with a high risk of bias 2++ High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+ GOOD PRACTICE POINTS  Recommended best practice based on the clinical experience of the guideline development group NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. SIGN guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline. This methodology is set out in the current version of SIGN 50, our guideline manual, which can be found at www.sign.ac.uk/guidelines/fulltext/50/index.html. The EQIA assessment of the manual can be seen at www.sign. ac.uk/pdf/sign50eqia.pdf. The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity Officer. Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site www.sign.ac.uk. This document is produced from elemental chlorine-free material and is sourced from sustainable forests. Scottish Intercollegiate Guidelines Network Management of sore throat and indications for tonsillectomy A national clinical guideline April 2010 ManageMent of sore throat and indications for tonsillectoMy isBn 978 1 905813 62 9 Published april 2010 SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland scottish intercollegiate guidelines network elliott house, 8 -10 hillside crescent edinburgh eh7 5ea www.sign.ac.uk contents 1 introduction ................................................................................................................ 1 1.1 The need for a guideline .............................................................................................. 1 1.2 Remit of the guideline .................................................................................................. 1 1.3 Definitions ................................................................................................................... 1 1.4 Statement of intent ....................................................................................................... 2 2 Key recommendations ................................................................................................. 3 2.1 Diagnosis and presentation .......................................................................................... 3 2.2 General management ................................................................................................... 3 2.3 Surgical management ................................................................................................... 3 2.4 Postoperative care ........................................................................................................ 3 3 Presentation ................................................................................................................ 5 3.1 Incidence of sore throat in general practice .................................................................. 5 3.2 Reasons for presentation in general practice ................................................................. 5 3.3 Emergency hospital admission...................................................................................... 5 4 diagnosis of sore throat............................................................................................... 6 4.1 Clinical diagnosis ......................................................................................................... 6 4.2 Throat culture .............................................................................................................. 7 4.3 Rapid antigen testing .................................................................................................... 7 5 general management of sore throat ............................................................................ 8 5.1 Pain relief in adults ...................................................................................................... 8 5.2 Pain relief in children ................................................................................................... 8 5.3 Adjunctive therapy ...................................................................................................... 9 6 antibiotics .................................................................................................................. 10 6.1 Antibiotics in acute sore throat ..................................................................................... 10 6.2 Antibiotics in recurrent sore throat ............................................................................... 11 6.3 Use of antibiotics to prevent rheumatic fever and glomerulonephritis ........................... 11 6.4 Use of antibiotics to prevent suppurative complications ............................................... 12 6.5 Use of antibiotics to prevent cross infection in sore throat ............................................ 12 7 surgery in recurrent sore throat .................................................................................. 13 7.1 Tonsillectomy rates for all surgical indications .............................................................. 13 7.2 Evidence for surgery in recurrent tonsillitis ................................................................... 13 7.3 Referral criteria for tonsillectomy for the treatment of recurrent tonsillitis ..................... 14 7.4 Otolaryngological assessment ...................................................................................... 15 7.5 Postoperative care ........................................................................................................ 16 contents control of Pain in adults with cancer 8 Provision of information .............................................................................................. 19 8.1 Sources of further information ...................................................................................... 19 8.2 Checklist for provision of information .......................................................................... 20 9 implementing the guideline ......................................................................................... 21 9.1 Auditing current practice ............................................................................................. 21 10 the evidence base ....................................................................................................... 22 10.1 Systematic literature review .......................................................................................... 22 10.2 Recommendations for research .................................................................................... 22 10.3 Review and updating ................................................................................................... 22 11 development of the guideline ..................................................................................... 23 11.1 Introduction ................................................................................................................. 23 11.2 The guideline development group ................................................................................ 23 11.3 Acknowledgements ...................................................................................................... 24 11.4 Consultation and peer review ....................................................................................... 24 abbreviations .............................................................................................................................. 27 annexes .................................................................................................................................... 28 references .................................................................................................................................. 35 ManageMent of sore throat and indications for tonsillectoMy 1 1 introduction 1 introduction 1.1 the need for a guideline The management of sore throat is a significant burden on health service resources. Most patients who seek advice see their general practitioner (GP) and in most cases the condition is relatively minor and self limiting. However, a significant number of patients experience unacceptable morbidity, inconvenience, and loss of education or earnings due to recurrent sore throat. The use of antibiotics in patients with recurrent sore throat has been controversial. The indications for tonsillectomy have long been a matter of debate. Tonsillectomy has a small but significant complication rate and an outcome that is not clearly defined. The guideline SIGN 34, Management of sore throat and indications for tonsillectomy, was published in 1999. Awareness of the guideline among physicians has led to more efficient and effective use of healthcare resources.1 In 2005 a consultation document identified the need for an update. This guideline updates SIGN 34 to reflect the most recent evidence. 1.2 reMit of the guideline 1.2.1 OvERAll ObjECTIvES This guideline covers diagnosis, pain management, antibiotic use, indications for surgical management and postoperative care for acute and recurrent sore throat in children and adults. It does not address tonsillectomy for suspected malignancy nor as a treatment for sleep apnoea or peritonsillar abscess. Specific surgical techniques, anaesthetic techniques and organisation of care, eg day case surgery, are not covered. The aim of this guideline is to suggest a rational approach to the management of acute sore throat in general practice and to provide criteria for referral for tonsillectomy in recurrent tonsillitis. The guideline also provides examples of patient information leaflets which may assist in management and facilitate decision making about the need for surgery (see Annexes 2 and 3) and suggests areas for further research (see section 10.2). 1.2.2 TARGET USERS Of THE GUIDElINE This guideline will be of particular interest to general practitioners, nurses, paediatricians, pharmacists, otolaryngologists, anaesthetists, public health specialists, patients with recurrent sore throat and their carers. 1.3 definitions Acute pharyngitis, tonsillitis, or acute exudative tonsillitis may all cause sore throat. for the purpose of non-surgical management, these are considered together under the term ‘sore throat’. No accepted definition of ‘childhood’ exists in Scots law or NHSScotland. Upper cut-off ages used in studies of children included in this guideline vary from 12 to 16. for the purposes of this guideline, recommendations concerning tonsillectomy in childhood apply to ages 4-16. for prescribing in children, advice in the bNf for Children should be followed.2 2 ManageMent of sore throat and indications for tonsillectoMy 1.4 stateMent of intent This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is advised, however, that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken. 1.4.1 PRESCRIbING Of MEDICINES OUTwITH THEIR MARkETING AUTHORISATION Recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed outwith the marketing authorisation (product licence). This is known as “off label” use. It is not unusual for medicines to be prescribed outwith their product licence and this can be necessary for a variety of reasons. Generally the unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience. To recommend a medicine outwith its Uk Marketing Authorisation it may be prescribed for: An indication not specified within the marketing authorisation ƒ Administration via a different route ƒ Administration of a different dose. ƒ ‘Prescribing medicines outside the recommendations of their marketing authorisation alters (and probably increases) the prescribers’ professional responsibility and potential liability. The prescriber should be able to justify and feel competent in using such medicines.’ 3 Any practitioner following a recommendation and prescribing a licensed medicine outwith the product licence needs to be aware that they are responsible for this, and in the event of adverse outcomes, may be required to justify the decisions that they have taken. Prior to prescribing, the licensing status of a medication should be checked in the current version of the british National formulary (bNf). 1.4.2 ADDITIONAl ADvICE TO NHSSCOTlAND fROM NHS qUAlITy IMPROvEMENT SCOTlAND AND THE SCOTTISH MEDICINES CONSORTIUM NHS qIS processes multiple technology appraisals (MTAs) for NHSScotland that have been produced by the National Institute for Health and Clinical Excellence (NICE) in England and wales. The Scottish Medicines Consortium (SMC) provides advice to NHS boards and their Area Drug and Therapeutics Committees about the status of all newly licensed medicines and any major new indications for established products. No relevant SMC advice or NICE MTAs were identified. 3 2 Key recoMMendations 2 Key recommendations The following recommendations were highlighted by the guideline development group as the key clinical recommendations that should be prioritised for implementation. The grade of recommendation relates to the strength of the supporting evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. 2.1 diagnosis and Presentation c the centor clinical prediction score should be used to assist the decision on whether to prescribe an antibiotic, but cannot be relied upon for a precise diagnosis. d throat swabs should not be carried out routinely in primary care management of sore throat. 2.2 general ManageMent a ibuprofen 400 mg three times daily is recommended for relief of fever, headache and throat pain in adults with sore throat. a in adults with sore throat who are intolerant to ibuprofen, paracetamol 1 g four times daily when required is recommended for symptom relief. a antibiotics should not be used to secure symptomatic relief in sore throat. 2.3 surgical ManageMent a watchful waiting is more appropriate than tonsillectomy for children with mild sore throats. a tonsillectomy is recommended for recurrent severe sore throat in adults. d the following are recommended as indications for consideration of tonsillectomy for recurrent acute sore throat in both children and adults: sore throats are due to acute tonsillitis ƒ the episodes of sore throat are disabling and prevent normal functioning ƒ seven or more well documented, clinically significant, adequately treated sore ƒ throats in the preceding year or five or more such episodes in each of the preceding two years or ƒ three or more such episodes in each of the preceding three years. ƒ 2.4 PostoPerative care ��; At the time of discharge, patients/carers should be provided with written information advising them whom to contact and at what hospital unit or department to present if they have postoperative problems or complications. d Patients should be made aware of the potential for pain to increase for up to 6 days following tonsillectomy. ��; Patients/carers should be given written and oral instruction prior to discharge from hospital on the expected pain profile and the safety profile of the analgesic(s) issued with particular reference to appropriate dose and duration of use. They should be issued with enough analgesic to last for a week. 4 ManageMent of sore throat and indications for tonsillectoMy a routine use of anti-emetic drugs to prevent postoperative nausea and vomiting (Ponv) in tonsillectomy is recommended. a a single intraoperative dose of dexamethasone (dose range 0.15 to 1.0 mg/kg; maximum dose range 8 to 25 mg) is recommended to prevent postoperative vomiting in children undergoing tonsillectomy or adenotonsillectomy. B a single dose of 10 mg dexamethasone at induction of anaesthesia may be considered to prevent Ponv in adults undergoing tonsillectomy or adenotonsillectomy. 2+ 5 3 Presentation 3 Presentation 3.1 incidence of sore throat in general Practice Most patients with sore throat do not attend their general practitioner (GP) to seek help with their condition.4 A Uk study of 516 women aged 20-44 yea