Acute sore throat

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Acute sore throat
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What else might it be?Prodigy

• Infectious mononucleosis (glandular fever)
• Epiglottitis (requires urgent admission)
• Thyroiditis
• Gonococcal pharyngitis (rare)
• Diphtheria (very rare in the UK)
• Neutropenia (ensure the person is not on
  medication known to cause immunosuppression)

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Sore throat Clinical Prediction Rule 1Centor RM,
et al. Med Decision Making 1981 1 23946

• Temp gt 38c 1
• Absence of cough 1
• Swollen, tender anterior cervical nodes 1
• Tonsillar swelling or exudate 1
• Score
• If 0 then lt1 chance of Strep (Group A Beta
  Haemolytic Streptococcus)
• If 3 of 4 approx 40 chance of Strep (Group A
  Beta Haemolytic Streptococcus )

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Clinical Prediction Rule 2McGinn TG, et al. Mayo
Clin Proc 2003 78 28993

• Validated in a cohort of 171 consecutive walk in
  patients. Overall prevalence of GABHS was 24
• Temp gt 38.3C 1 point Cough -1 point
  presence of pharyngeal or tonsillar exudates 1
  point enlarged or tender anterior cervical lymph
  nodes 1 point close contact with someone
  believed to have strep infection 1 point.

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Treatment options for sore throat? .

• Antibiotics
• Cochrane review. Del Mar CB, et al. Issue 3. 2004
  (26 RCTs 11,452 cases)
• Symptoms (headache, soreness and fever) reduced
  to half at day 3
• Non-suppurative complications trend to less
  glomerulonephritis (insufficient cases) and
  reduced rheumatic fever to one third (from older
  trials)
• Suppurative complications reduced complications
  of otitis media (NNT 87), acute sinusitis (NNT
  175) and quinsy (NNT 46)
• Analgesia
• Clinical Evidence. Del Mar C and Glazsiou P.
  Search date 2004
• Ibuprofen reduced throat pain at lt 24hrs and 25
  days
• In two RCTs, a single dose of paracetamol reduced
  sore throat pain at 23 hours compared with
  placebo, and in another paracetamol three times
  daily reduced pain at 2 days

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Antibiotics of limited value in sore throat?

• Little P. BMJ 19973147226
• 716 patients. Compared 10 day antibiotic
  prescription, no prescription and delayed
  prescription (3 days)
• Antibiotic associated with slightly reduced fever
  but no difference in number of days of illness,
  days off work or patients better at day 3.
• Zwart S, et al. BMJ 200332713247
• 308 children. Compared 4 day and 7 day Pen V with
  placebo. (severely ill excluded)
• No significant difference in duration of sore
  throat. Of 96 with positive GABHS throat swab,
  Pen V for 7 days also made no significant
  difference
• Concludes no rationale exists for treatment with
  antibiotics in most children with sore throat
• Rare complications e.g. rheumatic fever,
  peritonsillar abscess, mastoiditis. Very rare
  reports and overall rates remain steady despite
  reduced antibiotic prescribing (mastoiditis -
  increased hospital admissions and corresponding
  reduced GP episodes) Sharland M, et al. BMJ 2005
  331 32829

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Delayed prescription?

• Maybe a useful management strategy.
• Little P. BMJ 19973147226
• 69 given delayed prescription did not receive
  antibiotics
• More patients given antibiotics returned with
  subsequent sore throat
• (NNT 9)
• To avoid medicalising a self-limiting
  illness doctors should avoid antibiotics or offer
  a delayed prescription for most patients with
  sore throat

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Sore throatSummary

• Identify any differential diagnosis
• Undertake risk assessment for GABHS
• Antibiotics may make no difference to those not
  severely ill, even if they have GABHS (Zwart S,
  2003)
• Analgesia may help with sore throat pain
• Weigh up benefits versus risks of any antibiotic
  treatment
• If clinician concern (e.g. assessed high risk of
  severely ill), or patient / parental pressure to
  prescribe, consider a delayed prescription
  (Little P, 1997)