Art & science | throat infection

Use of antibiotics in the management of sore throat Ann Wilkinson describes how urgent care staff should manage people with sore throat and warns of the dangers of antibiotic resistance Correspondence [email protected] Ann Elizabeth Wilkinson is an emergency nurse practitioner at the minor injuries unit, Sir Robert Peel Community Hospital, Tamworth, Staffordshire, part of Burton Hospitals NHS Foundation Trust


Date of acceptance February 24 2015

As the number of antibiotic-resistant strains of bacteria rises, it becomes crucial that decisions about the use of antibiotics are based on sound evidence. This article offers a case study to explore the treatment of patients with sore throat who present to minor injury settings. It describes some ‘red flag’ presentations, discusses the pros and cons of prescribing antibiotics for sore throat, and describes some scoring systems that can help differentiate between bacterial and viral throat infections.

Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software

Keywords Sore throat, antibiotic use, antibiotic resistance, bacteria, antibacterial agents, scoring system

Date of submission December 25 2014

Author guidelines en-author-guidelines

SORE THROAT is a common presentation to primary and urgent care services. Of all people with sore throat who present to primary care services, the condition is due to viral infection in about 50%, bacterial infection in about 20%, and a non-infective cause, such as allergies, gastrointestinal reflux, mouth breathing and post nasal drip, in about 30% (Stephenson 2000, Cross and Rimmer 2002). Acute sore throat most commonly occurs in children aged between five and ten years, and in young adults aged between 15 and 25 years (National Prescribing Centre and National Institute for Health and Care Excellence (NICE) 1999). Hopcroft and Forte (2003) state that sore throat is the most over-treated of symptoms, but it can be considered an indicator, or ‘red flag’, for conditions such as epiglottitis and peritonsillar abscess, or quinsy, both of which require urgent referral to an ear, nose and throat specialist.

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Epiglottitis is caused by Haemophilus influenzae type b (Hib) bacteria and so has become less common in the UK since the Hib conjugate vaccine was introduced in 1992 (Public Health England 2013). It is characterised by rapid cellulitis, a temperature of more than 38°C and a severely swollen throat, and patients may drool due to an inability to swallow their saliva. If epiglottitis is suspected, the throat should not be examined with a tongue depressor because it could obstruct a severely swollen throat (Stevens 2008, NICE 2012). The most common bacterial cause of sore throat is Group A beta-haemolytic Streptococci (GABHS) (NICE 2012) and patients who present with this type of infection, rather than those with viral infection, are likely to benefit from antibiotic therapy (Summers 2005). A ten-day course of phenoxymethylpenicillin, or penicillin V, orally is the treatment of choice for GABHS tonsillitis (Scottish Intercollegiate Guidelines Network (SIGN) 2010). The case study opposite describes a typical presentation of a young person with sore throat.

Scoring systems There is no single sign or symptom that determines whether a throat infection is caused by a virus or a bacterium, so diagnoses must be based on a combination of factors. Practitioners can use scoring systems, such as the Centor, McIsaac and FeverPAIN systems, to help them decide whether antibiotics should be considered. Centor One of the most common scoring systems for decisions on whether to treat people with throat infections with antibiotics is the Centor system (SIGN 2010) EMERGENCY NURSE

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In this system, one point is awarded for each of four signs and symptoms: ■■ Absence of cough. ■■ History of fever. ■■ Tender anterior cervical lymph nodes. ■■ Tonsillar exudate. The likelihood of a GABHS infection increases with Centor score (SIGN 2010). Antibiotics should be considered for patients with a Centor score of three or more (NICE 2008, Pelucchi et al 2012). McIsaac system Like the Centor system, the McIsaac system (McIsaac et al 1998) involves awarding one point for each of four signs and symptoms: ■■ Absence of cough. ■■ Temperature of more than 38°C. ■■ Tender anterior cervical lymph nodes. ■■ Tonsillar swelling or exudate. In addition, one point is added if the patient is aged 15 years or under and one point deducted if the patient is aged 45 or over (McIsaac et al 1998). Prescription of antibiotics should be considered for patients with a McIsaac score of three or more (McIsaac et al 2000).

In a retrospective review of over 200,000 cases of sore throat in patients aged over three years, Fine et al (2012) have validated the Centor and McIsaac systems as good predictors of GABHS infection. FeverPAIN system Intended for assessing whether patients aged over five years should be prescribed antibiotics for sore throat, the FeverPAIN system (Little et al 2013) involves awarding one point for each of five signs and symptoms: ■■ Absence of cough and coryza. ■■ Fever. ■■ Purulence. ■■ Severely inflamed tonsils. ■■ Short previous illness. The most important of these signs and symptoms have been found to be fever, speed of presentation and the severity of tonsillar inflammation. Little et al (2013) could not confirm the importance of tender anterior cervical lymph nodes and tonsillar exudate as predictors of streptococcal infection, and warn that the system requires further validation.

Case study A 17-year-old female attended the minor injury unit (MIU) with a friend. She said she had had a sore throat for three days and that it was getting worse, and that the earliest appointment she could make with her GP was in two weeks. She also said she felt unwell and had a headache, but that she had taken no pain relief because it hurt her to swallow. The woman looked pale but was otherwise well. She was not drooling and had no stridor, and she was interacting normally with her friend. The patient said she had had all routine immunisations when at school, had no allergies and took no regular medications. She had no history of a cough. Standard observations revealed that the woman had a tympanic temperature of 38.5°C, her blood pressure was 128/72, pulse was 89 beats per minute, regular and calculated manually, oxygen saturation levels were 99%, and she had a central and peripheral capillary refill time of less than two seconds. Her respiration rate, counted over one minute, was 14 breaths per minute. All observations apart from the pyrexia were therefore within normal limits, and there were no ‘red-flag’ signs or symptoms, such as stridor or drooling. EMERGENCY NURSE

Examination of her ears, nose and throat revealed that her tonsils were enlarged and had visible pustules, her uvula was normal and not deviated, there was no trismus, no petechiae on her soft palate, and her tongue appeared normal. The girl’s anterior cervical lymph nodes were tender on palpation. Both of her tympanic membranes were normal and her nose was normal. She patient had Centor and McIsaac scores of four, and so a provisional diagnosis that she had tonsillitis, probably bacterial in origin, was made. The patient was supplied and administered with phenoxymethylpenicillin, or penicillin V, a narrow‑spectrum antibiotic with few side effects (National Institute for Health and Care Excellence 2012). She was given a five‑day course of the antibiotics, or half of the standard ten‑day course, according to the MIU’s relevant patient group directive. She was also advised to drink plenty of fluids, take pain relief when needed and monitor her illness. An appointment for her to see her GP after five days and receive the second half of the course of penicillin V was made. The patient was also given red-flag advice and information about how to access her local out-of-hours GP service. March 2015 | Volume 22 | Number 10 35

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Art & science | throat infection Management Treatment Patients with Centor or McIsaac scores of two or less can be advised on symptom-relief methods, such as increasing fluid intake and taking analgesia, and to consult their GPs if the signs and symptoms continue or worsen (Shepherd 2013). If no antibiotic therapy is advocated, patients should be reassured that it is unnecessary and can have side effects, such as diarrhoea, rash and vomiting (NICE 2008). Patients should also be advised to seek medical advice if their signs and symptoms continue or worsen. Clinicians should also explain to patients why antibiotics are not required at this point to reinforce messages about safe antibiotic use and the self‑management of future episodes of sore throat (Perry 2007). Such messages may help patients to realise that sore throat is often self‑limiting and can be managed by their immune systems. They may also reduce patients’ expectations about antibiotics (Van der Velden et al 2013). Some of the side effects of antibiotic use, such as antibiotic resistance and their effects on the gut flora, may be discussed at this time (Pelucchi et al 2012). In this context, the Global Respiratory Infection Partnership (GRIP) (2012) suggests that practitioners treating sore throats should: ■■ Address each patient’s concerns. ■■ Use a scoring system to assess the severity of the sore throat and whether severity is affected by the patient’s age or comorbidities such as diabetes. ■■ Counsel the patient on effective self-management if this is appropriate. GRIP (2012) also highlights signs and symptoms of sore throats that require further investigation. These ‘red-flag’ signs and symptoms include: ■■ Coughing up of blood. ■■ Drooling or having a muffled voice. ■■ Swallowing with great difficulty. ■■ Shortness of breath.

■■ Temperature of more than 39°C and night sweats. ■■ Unilateral swelling of the neck that is unrelated to the patient’s lymph nodes. ■■ Wheezing sounds during breathing. To differentiate between bacterial and viral tonsillitis, practitioners can take throat swabs. They can also carry out blood tests, such as white‑cell counts, or tests of C-reactive protein and procalcitonin levels, which are higher in patients with streptococcal tonsillitis compared with those without it (Carley 2011). However, in the context of UK general practice, the turnaround time for swab or blood results makes it unlikely that the results would make much difference to the immediate management of the patient (NICE 2012). Practitioners can also carry out rapid antigen detection tests to find out whether an infection is bacterial or viral in origin. These tests, which take between five and ten minutes, can be useful in primary care services (Lasseter 2009), although Little et al (2013) suggest that the use of scoring systems alone produces just as clear a guide to the origin of sore throat. Antibiotics According to GRIP (2012), antibiotic resistance is becoming a global threat, especially given the lack of new antibiotics, and that a ‘post‑antibiotic era’ may be approaching. In this context, the use of antibiotics in treating sore throats is much debated, and the World Health Organization (WHO) has devised a strategy to stop over‑prescription and prevent microbial resistance (WHO 2014). Whether due to bacterial or viral infections, sore throats are considered to be self-limiting. Studies show that, in 40% of people with sore throat, signs and symptoms resolve in three days and, in 85% of people, signs and symptoms resolve in one week (Spinks et al 2006, Kenealy 2011). Del Mar et al (2009) found that 90% of patients with sore throat of bacterial or viral origin were free of signs and symptoms after one week without being prescribed

References Carley SD (2011) Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. Emergency Medical Journal. 28, 8, 715-717. Cross S, Rimmer M (2002) Nurse Practitioner Manual of Clinical Skills. Ballière Tindall, London. Del Mar C, Glasziou P, Spinks A (2009) Antibiotics for sore throat. Cochrane Database of Systematic Reviews. 4. Fine A, Nizet V, Mandi K (2012) Large-scale validation of the Centor and McIsaac scores to predict Group A streptococcal pharyngitis. Archives of Internal Medicine. 172, 11, 847-852.

Gardener J (2012) Is fever after infection part of the illness or the cure? Emergency Nurse. 19, 10, 20-25. Global Respiratory Infection Partnership (2012) Antibiotic Misuse and Sore Throat Treatment. (Last accessed: February 25 2015.) Havinga W (2003) Time to counter fever phobia. British Journal of General Practice. 53, 488, 253. Hayward G, Thompson M, Perera R et al (2012) Corticosteroids as stand-alone or add-on treatment for sore throat. Cochrane Database of Systematic Reviews. 10. Hopcroft K, Forte V (2003) Symptom Sorter. Medical Press, Abingdon.

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Kenealy T (2011) Sore Throat: Clinical Evidence. BMJ Publishing Group, London. Lasseter GM, McNulty CA, Hobbs FD et al (2009) In vitro evaluation of five rapid antigen detection tests for Group A beta-haemolytic streptococcal sore throat infections. Family Practice. 26, 6, 437-444. Little P, Moore M, Hobbs F et al (2013) PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield Group A-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open. doi: 10.1136/bmjopen-2013-003943

McIsaac W, Goel V, To T et al (2000) The validation of a sore throat score in family practice. Canadian Medical Association Journal. 163, 7, 811-815. McIsaac W, White, D, Tannenbaum D et al (1998) A clinical score to reduce unnecessary antibiotic use in patients with sore throat. Canadian Medical Association Journal. 158, 1, 75-83. National Institute for Health and Care Excellence (2008) Respiratory Tract Infections: Antibiotic Prescribing: Prescribing of Antibiotics for Self-limiting Respiratory Tract Infections in Adults and Children in Primary Care. NICE, London.


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antibiotics, while Spinks et al (2006) claim that antibiotics are unlikely to shorten the mean duration of signs and symptoms by more than 16 hours. According to NICE (2008), there are three treatments for sore throats: ■■ Conservative, with no antibiotics. ■■ Immediate antibiotic therapy. ■■ Delayed antibiotic treatment, in which patients are given prescriptions for antibiotics but advised not to start taking them unless signs and symptoms continue or worsen after a specified period of time. Post-dated prescriptions act as a safety net for patients in case they develop complications. However, many patients with sore throat expect to be prescribed antibiotics and, if such treatments are delayed, may ignore advice and take them immediately (Perry 2007). Sore throat can also be caused by diseases transmitted by oral sex, such as gonorrhoea, syphilis and that caused by Chlamydia trachomatis (Rani and Cunill De Sautu 2011), which can be diagnosed from throat swabs. Another differential diagnosis is glandular fever, in which patients present typically with fatigue, fever, generalised lymphadenopathy, rather than just cervical lymph node involvement (Perry 2007). Tonsillitis occasionally gives rise to complications, such as rheumatic fever (Richardson 2011). Pain relief According to Van Driel et al (2006), patients with sore throat who ask for antibiotics may actually want pain relief, and by providing this, practitioners can manage patients without prescribing antibiotics. SIGN (2010) recommends ibuprofen 400mg three times daily or, for patients unable to tolerate ibuprofen, paracetamol 1g four times daily. Schams and Goldman (2012) suggest that steroids can be of value in pain management, a single dose of dexamethasone in addition to antibiotics leading to quicker onset of pain relief in patients with bacterial sore throat.

National Institute for Health and Care Excellence (2012) Clinical Knowledge Summaries. Sore Throat: Acute. (Last accessed: February 25 2015.) National Prescribing Centre, National Institute for Health and Care Excellence (1999) Managing sore throats. MeReC Bulletin. 10, 11, 41-44. Pelucchi C, Grigoryan L, Galeone C et al (2012) Guideline for the management of acute sore throat. Clinical Microbiology and Infection. 18, Supplement 1, 1-27. Perry M (2007) Management of sore throat. Practice Nurse. 33, 11, 15-19.


Although steroid therapy can suppress the immune system, Hayward et al (2012) conclude that oral steroids in addition to antibiotics can improve pain relief in people with sore throat, and that there is no difference in rate of relapse and number of adverse events between people taking corticosteroids and those taking placebo. In guidelines for managing acute sore throat, Pelucchi et al (2012) advocate consideration of steroid therapy with antibiotics for adults with severe sore throat. Fever Traditionally, fever has been regarded as a symptom of an illness to be treated in its own right (Walsh et al 2008). An increase in body temperature is a vital response to infection, however, and helps to create an unfavourable environment for invading bacteria (Gardener 2012). Consequently, chemically reducing fever can prolong disease (Havinga 2003). The consensus at present is to use antipyretic drugs for controlling pain and discomfort rather than fever, especially in children (Gardener 2012).

Conclusion Sore throat is a common presentation in healthcare settings. Most sore throats are viral in origin, self-limiting and do not require treatment with antibiotics. It is important to inform patients about this, although every case should be considered individually. The Centor guidelines are useful for differentiating between patients who are likely to benefit from antibiotic therapy and those who are not. It is important that antibiotic therapy is offered only when it is needed because unnecessary use contributes to antibiotic resistance. Patients should be informed that using antibiotics inappropriately, for example by taking them at irregular intervals, skipping doses or failing to finish courses, is helping to drive antibiotic resistance.

Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared

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Shepherd A (2013) Assessment and management of acute sore throat. Nurse Prescribing. 11, 11, 549-553.

improved diagnosis, enhanced self‑care and more rational use of antibiotics. International Journal of Clinical Practice. 67, Supplement 180, 10-16.

Rani G, Cunill De Sautu B (2011) Throat infections. Paediatrics in Review. 32, 11, 459-469.

Spinks A, Glasziou P, Del Mar C (2006) Antibiotics for sore throat. Cochrane Review. 4.

Richardson K (2011) Non-antibiotic treatment of sore throat. Emergency Nurse. 18, 9, 12-17.

Stephenson K (2000) Acute and chronic pharyngitis across the lifespan. Lippincott’s Primary Care Practice. 4, 5, 471-489.

Van Driel M, De Sutter A, Deveugele M et al (2006) Are sore throat patients who hope for antibiotics actually asking for pain relief? Annals of Family Medicine. 4, 6, 494-499.

Schams SC, Goldman RD (2012) Steroids as adjuvant treatment of sore throat in acute bacterial pharyngitis. Canadian Family Physician. 58, 1, 52-54. Scottish Intercollegiate Guidelines Network (2010) Management of Sore Throat and Indications for Tonsillectomy. (Last accessed: February 25 2015.)

Stevens D (2008) A sore throat or something else? Practice Nursing. 19, 2, 83-85. Summers A (2005) Sore throats. Accident and Emergency Nursing. 13, 15-17. Van der Velden A, Bell J, Sessa A et al (2013) Sore throat: effective communication delivers

Walsh A, Edwards H, Fraser J (2008) Parents childhood fever management: community survey and instrument development. Journal of Advanced Nursing. 63, 4, 376-388. World Health Organization (2014) Antimicrobial Resistance: Fact Sheet 194. WHO, Geneva.

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Use of antibiotics in the management of sore throat.

As the number of antibiotic-resistant strains of bacteria rises, it becomes crucial that decisions about the use of antibiotics are based on sound evi...
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