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Management of Sore Throat

Watch the video to hear specific details relating to the management of sore throat.
So now, I’m going to move on to antibiotics and acute sore throat. So the focus specifically on the research relating to this. And then to think about how best to manage acute sore throat. What the best evidence is now. So again, we’re going to think about symptom benefit. Avoiding complications. Patient demand. And then targeting those at high risk. So if we look at that nice guideline chart, again, but focusing on sore throat– you can see that, on average, people wait around three days before they see the doctor. They have symptoms for five to seven days after they’ve seen the doctor. So we’ll have symptoms for seven to 10 days.
And you might expect a 12 to 24-hour reduction in symptoms giving an antibiotic prescription. This is data from a randomised controlled trial of people with acute sore throat and the three groups represented on this graph are people randomised to immediate antibiotics, delayed antibiotics, or no antibiotics. And this shows the proportion recovered over time. And it’s really difficult to tell the difference between those three lines. So any of those strategies result in similar patient outcomes. Thinking about complications, we’ve collected some observational data to inform the risk of complications. If you look at trial data– although it’s very helpful looking at outcomes in terms of symptoms, there aren’t enough people in trials to determine whether antibiotic strategies influence complication rates.
So we collected information on nearly 14,000 adults presenting with an acute sore throat. And a relatively small number of them went on to develop complications– just over 1%. And around about three in 1,000 ended up with a quinsy following that presentation. We looked at predictors of adverse outcome and we did find two predictors of adverse outcomes– severe ear pain and severe tonsil inflammation. But the odds ratios of those– just over two– weren’t that helpful in clinical practice when complications are so rare. So just as a rule of thumb to think about what happens after a sore throat consultation– around one in 10 people will re-consult. Around one in 100 will have a separate complication of some kind.
And one in 1,000– a significant complication. And it’s hard to determine, in advance, who’s going to go on and get one of those more significant complications.
We also use that same data set to look at the outcome according to antibiotic strategy. And that was immediate antibiotics, a delayed, or just in case prescription, or no antibiotic prescription. And we showed that antibiotics were associated with a reduction in separate complications– around about 1/3. But interestingly, delayed antibiotics appeared to have the same or similar effect.
So currently, what do the NICE guidance say? They suggest we use a scoring system called Centor. And they recommend that if you have a score of three or more and the score consists of pus on the tonsils, a history of fever, presence of tender lymph nodes, and the absence of cough– they say if you have a score of three or more, then you can consider an antibiotic. Otherwise, use no antibiotic or a delayed antibiotic strategy. So the NICE guidance is suggesting some targeting to those at high risk.

Watch the video to hear specific details relating to the management of sore throat.

Michael focusses on the evidence looking at the effectiveness of the prescribing of antibiotics for sore throat and presents the current guidelines for managing sore throat.

The current NICE guidance advises paracetamol or if preferred a suitable ibuprofen for pain, and to use the Centor or FeverPAIN scoring symptoms to indicate when to prescribe antibiotics. A useful tool is the NICE visual summary for acute sore throat.

Antibiotics should only be prescribed if the FeverPAIN score is 4-5 (Fever, Pus on tonsils, Attend rapidly, severely Inflamed tonsils, No cough or coryza) or the Centor score is 3-4 (pus, temperature, glands and no cough).

If FeverPAIN is 2 or 3 consider no antibiotic or back up antibiotic. If FeverPAIN is 0 or 1 or Centor is 0, 1 or 2 then do not offer an antibiotic.

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TARGET Antibiotics – Prescribing in Primary Care

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