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Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Throat Infections, Emergency Medicine, Paediatrics (336)

Warning Warning: This guideline is 118 day(s) past its review date.

Objectives

Guidance for the assessment and management of throat infections in children. 

Scope

Children presenting to hospital (RHC) with a sore throat.

Audience

Medical and nursing staff assessing children presenting with sore throat in the ED and CDU at RHC.

November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.

An acute sore throat is a common presentation to the paediatric emergency department.   The majority of sore throats resolve within 1 week irrespective of the cause (40% within 3 days and 85% within 1 week)1.  There are many causes of sore throats and it is important to identify the life-threatening causes as well as sore throat caused by Group A Streptococcus (GAS) as this needs antibiotics to prevent possible complications.

Sore throat can be bacterial, viral or non infectious (GORD, hayfever, smoke).  The most common viral cause is rhinovirus (20%)3 and the most common bacterial cause is group A streptococcus (GAS)(10-30%)2

Clinical features alone do not reliably discriminate between bacterial and viral causes but can give us some guidance on diagnosis.

Symptoms suggestive of viral or GAS

Viral

Group A streptococcal

(aged 1-3 years)

Group A streptococcal

(most common aged 3-14 years)

Conjunctivitis

Mucopurulent rhinitis

Sudden onset sore throat

Rhinorrhoea

Excoriated nares

Dysphagia

Cough

Diffuse adenopathy

Fever

Oral ulcers

Exudative pharyngitis (rare)

Headache

Hoarseness

 

Nausea and vomiting

Rash

 

Abdominal pain

Diarrhoea

 

Red swollen tonsils and uvula

Wheeze

 

Patchy exudates on pharynx

 

 

Palatine petechiae

 

 

Anterior cervical adenitis

 

 

Scarlatiniform rash

McIsaac score (modified centor criteria)2

The Centor criteria are only validated for adult patients in primary care and are not validated for children under the age of 3 due to the different clinical presentation of GAS in the first years of life.  The McIsaac score (modified centor criteria) can be used in patients over 3 years old and takes into account the higher rate of streptococci in the 3-14 year age group.  NICE recommends prescribing antibiotics if the patient scores 3 or more.

History of fever add 1 point
Tonsillar exudate  add 1 point
Tender enlarged cervical lymph nodes  add 1 point
Absence of cough    add 1 point
Ages 3-14   add 1 point
Ages 15-44 add 0 points

 

McIsaac score

Percentage risk of GAS4

0

1-2.5%

1

5-10%

2

11-17%

3

28-35%

4-5

51-53%

The FeverPAIN criteria5,6,7            

The Fever PAIN score was derived from a cohort study including 1760 adults and children aged 3 and over.

The score was tested in a trial comparing three prescribing strategies, empirical delayed prescribing, use of the score to direct prescribing or combination of the score with use of a near patient test (NPT) for streptococcus. Using the score resulted in more rapid symptom resolution and reduced prescribing of antibiotics (both reduced by one third). The addition of the NPT did not confer any additional benefit.

The score consist of five items:

  • Fever during previous 24 hours;
  • Purulence;
  • Attend rapidly (<=3 days);
  • very Inflamed tonsils;
  • No cough/coryza

Each of the FeverPAIN criteria score 1 point (maximum score of 5)

FeverPAIN score

Likelihood of isolating streptococcus

0 or 1

13-18%

2 or 3

34-40%

4 or 5

62-65%

Please note most GAS infections self resolve without complications

Supparative

Occur shortly after initial infection

Non supparative

Occur after few weeks-rare in UK

Acute otitis media (most common)

Acute rheumatic fever

Quinsy (peritonsillar abscess)

Poststreptococcal glomerulonephritis

Retropharyngeal abscess

Reactive arthritis

Cervical adenitis

 

Mastoiditis

 

Acute bacterial sinusitis

 

Septicaemia

 

Meningitis

 

Empyema

 

Throat swabs

NICE recommends that throat swabs are not routinely taken.  This is due to turnaround time of 48 hours, poor sensitivity and they cannot differentiate between infection and carriage. 

A positive throat culture makes GAS more likely but a negative throat culture does not rule out diagnoses. 

Children have a high rate of asymptomatic carriage of GAS (40%)8.  Carriers have low infectivity and are not at risk of developing complications.

However our departmental policy is that if the child is being treated with an antibiotic for likely GAS then it is useful to swab their throats before treatment in case of failure to respond to antibiotics. 

If EBV is being considered then viral throat swabs should also be taken.

 

Bloods

Bloods are not recommended to differentiate between bacterial and viral infections.  However, if suspected EBV, then bloods can be taken as per EBV guideline.

 

Rapid antigen testing  - Not currently routinely available in RHC ED.

A systematic review of RCTs9 reviewing rapid antigen detection test (RADT) for group A streptococcus in children with pharyngitis found that RADTs have high sensitivity and specificity for identifying GABHS infection. In studies that compared rapid antigen testing and throat culture, rapid antigen testing had a summary sensitivity of 85.6% and a summary specificity of 95.4% (based on very low-quality graded evidence).  

Clinical bottom line -  using RADT you can expect that amongst 100 children with strep throat, 86 would be correctly detected with the rapid test while 14 would be missed and not receive antibiotic treatment. Of 100 children with non-streptococcal sore throat, 95 would be correctly classified as such with the rapid test while 5 would be misdiagnosed as having strep throat and receive unnecessary antibiotics.

If the child has stridor, respiratory distress, drooling or is systemically very unwell they should be have urgent PICU review. 

If the child is going to be discharged home then they should be given advice as below:

  • Avoid hot drinks
  • Take adequate fluid to avoid dehydration
  • Gargle with warm salty water at frequent intervals until the discomfort and swelling subside (age appropriate)
  • Suck throat lozenges, hard boiled sweets, ice or ice lollies
  • Use Benzydamine spray (Difflam) (there is no good clinical evidence of effectiveness but many children find this helpful)
  • Use Paracetamol first line with Ibuprofen as alternative
  • Advise that if the child worsens or has a prolonged illness then they should be reviewed.

Antibiotics should be considered if a child over 3 years old has 3 or more McIsaac criteria and symptoms significant enough to warrant treatment.  Phenoxymethylpenicillin or Clarithromycin (if true penicillin allergy) should be used.  Antibiotics should be prescribed as per current NHS GGC empirical antibiotic guidelines.

There is no validated scoring system for bacterial tonsillitis in children under 3 years of age.  Decision to treat this age group with antibiotics is based on clinical judgement.

Amoxicillin or Co-amoxiclav should not be used as this can cause a significant rash in patients with infectious mononucleosis.

Cause

Symptoms

Investigations

Treatment

Peritonsillar abscess (Quinsy)

-severe sore throat often unilateral

-hot potato voice

-drooling

-trismus

-neck swelling

-referred ear pain

 

Discuss with ENT regarding IV antibiotics and drainage

Epiglottitis or bacterial tracheitis

 

(more likely if not immunised against HIB)

 

-abrupt onset respiratory distress

-absent cough with low pitched stridor

-muffled/hoarse voice

-tripod/sniffing positioning

-drooling

-fever

-do not examine throat, do venepuncture or lateral neck x-ray in patients with severe respiratory distress due to risk of precipitating respiratory arrest

 

-early PICU review

-maintain position of comfort with parents present

-discuss with ENT regarding IV antibiotics

Retropharyngeal abscess/lateral pharyngeal abscess

Retropharyngeal

-respiratory distress

-stridor

-dysphagia

-odynophagia

-drooling

-torticollis

-muffled voice

-neck mass

-trismus

-chest pain

Lateral pharyngeal

-as above with swelling below mandible

-lateral neck x-ray (normal does not exclude diagnosis)

-CT with IV contrast with access to advanced airway management

 

-Early ENT +/- PICU review

-Discuss with ENT regarding IV antibiotics

 

Infectious mononucleosis (glandular fever/EBV)

-suspect if sore throat fails to improve/worsens

-enlarged tonsils with thick white exudate

-palatal petechiae

-fever

-generalised lymphadenopathy

-fatigue/malaise

-variable hepatosplenomegaly

-amoxicillin induced rash

-symptoms usually resolve in 1-2 weeks but lethargy can last months to years

Complications

-meningitis/encephalitis

-hepatitis

-myocarditis

-orchitis

-cytopenias

-lymphoproliferation

-splenic rupture

-FBC, U+E, LFTs

-glandular fever screening test (monospot)-may be negative in early phase and is unreliable under 4 years

-EBV IgG and IgM

- viral throat swab-(PCR for EBV specifically requested)

-analgesia

-hydration

-consider corticosteroids

 

-if well and bloods normal-GP follow up with referral if still feverish in 1 week

-if well and bloods mildly deranged-hospital follow up

-if unwell then admit under medics and discuss with infectious diseases

[10]

Editorial Information

Last reviewed: 05/06/2018

Next review date: 31/10/2024

Author(s): Dr Ciara Duthie, GP trainee, RHC ED., Dr Steve Foster, Consultant in Paediatric Emergency Medicine, RHC ED (correspondence author)..

Version: 3

Approved By: Paediatric Emergency Department

Document Id: 336

References
  1. NICE CKS-sore throat acute
  2. Spinks et al. Antibiotics for sore throat. The Cochrane Library 2013.
  3. Kanji K., et al, 2016. Antibiotics for tonsillitis: Should the emergency department emulate general practice?. Journal of clinical pathology. 69 (9), pp. 834-836
  4. Dynamed Plus. Pharangitis. http://www.dynamed.com/topics/dmp~AN~T114913/Pharangitis
  5. Escmid sore throat guideline group, et all, 2012. Guideline for the management of acute sore throat.  Clinical Microbiology & Infection, 18 (Suppl 1), pp.1-28
  6. Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Delaney B, et al. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis. 2014.
  7. Little P, Hobbs FR, Moore M, Mant D, Williamson I, McNulty C, et al. PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess. 2014;18(6):1-102.
  8. Little P, Moore M, Hobbs FD, Mant D, McNulty C, Williamson I, et al. PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A beta-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open. 2013;3(10):e003943
  9. SIGN 117: Management of sore throat and indications for tonsillectomy (Feery BJ, Forsell P, Gulasekharam M. Streptococcal sore throat in general practice-a controlled study. Med J Aust 1976; 1 (26):989-91
  10. Cochrane Database Syst Rev. 2016 Jul 4;7:CD010502.  Rapid antigen detection test for group A streptococcus in children with pharyngitis.  Cohen JF, Bertille N, Cohen R, Chalumeau M.
  11. Royal Hospital Children Australia –Sore thoat guideline