- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03744832
Point of Care Streptococcal Pharyngitis Testing
Point of Care Group A Streptococcal Testing in a Pediatric Emergency Department: A Randomized Controlled Trial
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Purpose:
Molecular-based, nucleic acid amplification tests (NAATs), have been proposed as a diagnostic solution for streptococcal pharyngitis. Indeed, available data suggest that NAATs have similar performance to conventional culture testing, and point of care (POC) NAATs recently became commercially available. These bedside tests do not require operation by laboratory personnel and have been approved by Health Canada for use without the need for backup culture testing. This study seeks to compare the clinical outcomes of a POC NAAT approach with a conventional bacterial culture-based approach for children presenting to a Pediatric Emergency Department (PED) with suspected streptococcal pharyngitis. Results from this clinical trial will elicit critical information regarding the potential clinical benefit of implementing this new technology in the PED.
Hypothesis:
The investigators hypothesize that clinical outcomes (duration of illness, incidence of complications, absenteeism) and system utilization (PED length of stay, ancillary testing, return visits to hospital or community healthcare facility, appropriate antibiotic treatment) will improve with a POC NAAT diagnostic approach for suspected streptococcal pharyngitis.
Justification:
Determining the etiology of pharyngitis is necessary, both to minimize inappropriate antimicrobial therapy for viral infections, and to reduce the incidence of complications, duration of illness, and transmission of streptococcal infections, for which antibiotics are indicated. However, signs and symptoms of viral and streptococcal pharyngitis overlap significantly, and accurate differentiation based on history and clinical examination is difficult even for experienced clinicians. As a result, the Infectious Diseases Society of America (IDSA) currently recommends swabbing the throat and testing for streptococcal pharyngitis by culture, which is the current standard of practice at BC Children's Hospital (BCCH). However, while bacterial cultures are accurate and economical, they are often clinically impractical and cause delay in treatment due to the relatively long lag time (>48 hours) between collection of the specimen and final microbiological diagnosis. Available data suggest that new POC NAATs have similar performance to conventional culture testing with results available within 8 minutes. This could potentially improve clinical outcomes and reduce system utilization, but implementation would require significant task shifting, logistical support, and additional training. This study will provide an impact evaluation of this new technology in a PED, which is a necessary first step prior to implementation, in an effort to ultimately improve care for children and youth while minimizing costs to society.
Objectives:
The primary objective of this study is to compare POC NAAT testing with conventional throat culture testing (the current standard of care) for children and adolescents presenting to a PED for suspected streptococcal pharyngitis with regards to clinical management, symptom resolution, and resource utilization.
Demographic and Visit Characteristics:
- Age in years
- Sex (Male or Female)
- Triage acuity level using the Canadian Triage and Acuity Scale (CTAS)
- Visit day of the week (weekday/weekend/holiday)
- Length of stay (minutes) using date and time of arrival (registration/triage) and date and time of discharge
- McIsaac score (0-5)
- Disposition
Statistical Analysis:
Descriptive statistics will be used to summarize study population demographic and baseline characteristics. The Student t-test will be applied for continuous variables (mean time to symptom resolution, mean days off, etc.), and the chi-square test will be applied for categorical variables (proportion appropriately treated).
Quality Assurance:
Left over swabs from either study arm will be stored to subsequently culture or conduct NAAT testing for patients randomized to the interventional (POC testing) or standard (conventional culture) study arms, respectively. This alternate method testing will not be conducted until the end of the study, unless culture and sensitivity testing is required earlier for a patient that is randomized to the interventional POC study arm with a known severe beta-lactam allergy and/or does not respond to second-line therapy. The POC test performance will not be evaluated as part of this study as it has been determined to be at least equivalent to culture detection in the past.
Sample size estimation:
Using published literature on the effect of antibiotics on GAS pharyngitis, we estimate that the mean time to resolution in the POC group is 3 days (with a standard deviation of 2 days), and a minimally important difference in mean time to resolution between the groups being 1.5 days. Using 80% power at a significance level of 0.05, the required sample size is 28 subjects per group. With an estimated 30% positivity rate, and accounting for 10% of individuals lost to follow-up, the investigators will aim to recruit 100 subjects per group.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
British Columbia
-
Vancouver, British Columbia, Canada, V6H 3N1
- BC Children's Hospital
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Children 3-17 years of age who seek care in a ED with sore throat, and in whom the ED clinician is considering a throat swab for culture for suspected GAS pharyngitis. In addition, only English speaking families will be recruited.
Exclusion Criteria:
- Patients younger than 3 and older than 17 years of age will be excluded. In addition, patients who had a throat swab completed and/or were treated with antibiotics prior to presenting to the ED for the current illness, and patients with underlying cardiorespiratory illness will be excluded.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: DIAGNOSTIC
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
EXPERIMENTAL: Point of Care Testing
Point of care testing using the Alere i™ Strep A assay for patients randomized to this study arm when presenting with suspected streptococcal pharyngitis and having their throat swabbed. If test is positive, patients will be started on antibiotics prior to discharge from the ED. If test is negative, patients will not be started on antibiotics. At home, the patient family will be asked to complete an online survey and/or keep a written diary daily detailing their clinical course following discharge from the ED. |
Point of care (POC) molecular-based, nucleic acid amplification test (NAAT).
This isothermal molecular assay is CLIA waived (Clinical Laboratory Improvement Amendments) and Health Canada licensed for POC use, and is anticipated to have approval for use without need for back up culture testing.
|
ACTIVE_COMPARATOR: Standard Care
Conventional testing using a standard bacterial throat culture for patients randomized to this study arm when presenting with suspected streptococcal pharyngitis and having their throat swabbed. Patients will be discharged with a post-dated prescription and will be contacted in approximately 3 days if their culture results are positive to fill/take the antibiotics. At home, the patient family will be asked to complete an online survey and/or keep a written diary daily detailing their clinical course following discharge from the ED. |
Standard bacterial throat culture.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Sore throat resolution.
Time Frame: 7 days.
|
Mean time in half-days from ED discharge to sore throat resolution (POC vs. standard).
|
7 days.
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Fever resolution.
Time Frame: 7 days.
|
Mean time in half-days from ED discharge to fever resolution (axillary temperature; POC vs. standard).
|
7 days.
|
Appropriate antibiotic utilization by patients/families.
Time Frame: 7 days.
|
Proportion of patients appropriately treated with antibiotics (ie.
streptococcal-positive treated with antibiotics and streptococcal-negative not started on antibiotics.
Families may decide to fill prescription without a positive culture result or families may obtain a prescription from elsewhere despite a negative POC test in the ED; POC vs. standard).
|
7 days.
|
Calls averted.
Time Frame: 7 days.
|
Number of patient calls averted (POC vs. standard).
|
7 days.
|
Parental Absenteeism.
Time Frame: 7 days.
|
Mean number of days away from work for a parent (measured by half day units; POC vs. standard).
|
7 days.
|
Child Absenteeism
Time Frame: 7 days
|
Mean number of days away from school/daycare for a child
|
7 days
|
Healthcare return visits.
Time Frame: 7 days.
|
Proportion of patients with a least 1 ED re-visit or community healthcare facility visit for the same illness within 7 days (POC vs. standard).
|
7 days.
|
Length of stay.
Time Frame: 7 days.
|
length of stay (LOS) will be calculated from time of registration/triage until discharge (POC vs. standard).
|
7 days.
|
Ancillary testing.
Time Frame: 7 days
|
May include, but is not limited to, a complete blood count, urinalysis, urine culture, blood, culture, or neck/chest radiographs (POC vs. standard).
|
7 days
|
Collaborators and Investigators
Sponsor
Study record dates
Study Major Dates
Study Start (ACTUAL)
Primary Completion (ACTUAL)
Study Completion (ANTICIPATED)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ACTUAL)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- H18-02371
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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