Sore throat – when to use antibiotics

This is a new guideline from NICE which advises on when to use antibiotics in patients with tonsillitis or sore throat. If you already use a scoring system to help you decide when to prescribe it doesn't change a lot. Take home points: use a scoring system (FeverPAIN or Centor) and prescribe penicillin 500mg QDS or 1g BD for 5 - 10d.

There is a fantastic 2 page, stick it on your wall guide from NICE which summarises it all nicely.

Useful background information on sore throats and antibiotics

  • About 20% of cases are bacterial and most of those are Group A beta-haemolytic strep (GABHS).
  • Complications are rare (eg NNT = 200 to prevent 1 case of otitis media).
  • Most people are better within a week, whether it is bacterial or viral.
  • Antibiotics on average shorten the illness by about 16 hrs over 7d.

FeverPAIN and Centor

Use one of these scoring tests to help you decide whether to prescribe antibiotics. At present there is no clear indication which is better in a GP population in the UK, so using either is OK. I'll give a bit of information about each as it may help you decide which works better for you.

FeverPAIN - score 1 each for:

  • Fever.
  • Purulence.
  • Attends within 3d.
  • Severely inflamed tonsils.
  • No cough or coryza.

A score of 4 or 5 gives a 62 - 65% positive predictive value. Adding in a swab in addition to using FeverPAIN has no clear advantage in reducing antibiotic prescribing. It was developed in a UK primary care setting, but hasn't been externally validated (hence the caution regarding advising using this test over Centor).

Centor - score 1 each for:

  • Tonsillar exudate.
  • Tender anterior cervical lymph nodes.
  • History of fever (> 38 deg).
  • No cough.

A score of 3/4 gives a positive predictive value of 32 - 56%. It was developed in a US ED setting in adults.

Advice to give patients about sore throat and tonsillitis

  • Need reassessing if they worsen rapidly or significantly or get systemically very unwell.
  • Use paracetamol +/- ibuprofen (NB aspirin and diclofenac work just as well, but with more side-effects).
  • Adequate fluid intake.
  • Medicated lozenges in adults may decrease pain a bit (eg ones with local anaesthetic, NSAID or antiseptic).
  • There is no evidence on the use of non-medicated lozenges, mouthwashes and local anaesthetic sprays.

Who to treat and how

  • FeverPAIN 0/1 or Centor 0/1/2 - no antibiotics.
  • FeverPAIN 2/3 - Consider no antibiotic or a back-up antibiotic script. NB - there is evidence from some RCTs, that in this group, giving a back-up script or no antibiotics makes no difference either to duration of the illness nor to symptom severity. However other RCTs suggest there can be a benefit. None of the studies showed a difference in complication rates.
  • FeverPAIN 4/5 or Centor 3/4 - Consider an immediate antibiotic, or a back-up antibiotic (the latter especially if symptoms are mild and improving).
  • In patients who are very unwell, or who are at risk of complications, or who have complications, then give an immediate antibiotic script.

Back-up antibiotic scripts should be used after 3 - 5d if the patient is not improving, or if they worsen rapidly of significantly (in which case they should also be seeking review).

 What antibiotics should you prescribe?

  • Penicillin 500mg QDS or 1g BD for 5 - 10d.

1g BD has been found in some studies to be as effective as 500mg QDS, if the patient is GABHS +. It may improve adherence.

5d has been suggested as there is no difference in relapse or recurrence compared to a 10d course. However there is a lower microbiological cure, so they advise 10d if the patient has recurrent symptoms.

  • 2nd line treatment is clarithromycin for 5d, or erythromycin (250 - 500mg QDS or 500 - 1000mg BD) for 5d.

Obviously doses will be different for kids.

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