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By Rahul Gupta, MD, MPH, FACP
Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV
Dr. Gupta reports no financial relationships relevant to this field of study.
Synopsis: A study of patients with acute sore throat finds that a delayed prescription strategy prevents complications as effectively as immediate antibiotics, and that the delayed prescription approach is more effective than immediate antibiotics at reducing revisits.
Source: Little P, et al. Antibiotic prescription strategies for acute
sore throat: A prospective observational cohort study.
Lancet Infect Dis 2014;14:213-219.
Acute pharyngitis, or sore throat, is one of the most common conditions encountered in an office practice in the United States. While bacterial (mostly group A streptococcus) etiology accounts for approximately only 10% of the total cases of pharyngitis and the major complications are rare, a majority of patients continue to receive presumptive antibiotic therapy.1 Recent estimates demonstrate that as many as 60% of adults seen for a complaint of sore throat received an antibiotic prescription, with a trend toward prescribing broader-spectrum antibiotics (azithromycin) rather than narrow-spectrum antibiotics (penicillin).2 Improper antibiotic prescribing is among several factors contributing to a growing epidemic of antibiotic resistance in the United States. In the clinical practice setting, physicians continue their efforts to reduce inappropriate antibiotic prescribing, including the use of clinically validated decision protocols when applicable. However, sometimes the avoidance of antibiotic prescribing in patients becomes a challenge, especially when concerns for clinical complications from pharyngitis are considered. Additionally, even when treating documented bacterial pathogens such as group A streptococcus, antibiotics may contribute minimally to the pace at which symptoms of pharyngitis resolve. Data from trials of antibiotics in acute pharyngitis suggest only moderate benefits in symptoms and prevention of complications.3 One strategy that seems to have had some success is the delayed provision of antibiotic prescriptions, in which the patient is prescribed an antibiotic that should be taken only in case of worsening of the symptoms or no improvement a few days after the visit. However, when evaluated scientifically, such studies have been underpowered to address symptom progression and complications.4
In their research, Little et al utilized a prospective, observational cohort study design involving 12,677 adult primary care patients in England and Wales who presented with a sore throat. Follow-up of the cohort was based on a detailed and structured review of the routine medical records and analysis of the comparison of three antibiotic prescription strategies (no antibiotic prescription, immediate antibiotic prescription, and delayed antibiotic prescription) to control for the propensity to prescribe antibiotics. A total of 4805 patients received no antibiotics, 6088 received antibiotics immediately, and 1784 received delayed prescriptions.
The researchers found that complications (such as otitis media and sinusitis) occurred in 164 of 11,950 patients (1.4%). In comparison with no antibiotic treatment, the risk of complications was 42% lower with delayed antibiotic treatment and 38% lower with immediate antibiotic treatment. The estimated number needed to treat (NNT) was 174 with delayed treatment and 193 with immediate antibiotic treatment. They also found that the rate of re-consultation for new or unresolved symptoms was 39% lower with delayed antibiotics (NNT = 18) and 17% lower with immediate antibiotics (NNT = 40). In summary, the delayed prescription of antibiotics was associated with both a lower risk of complications and persistent symptoms than immediate prescription of antibiotics.
Antibiotic resistance has been called one of the world’s most urgent public health challenges. There is no doubt that the number of bacteria resistant to antibiotics has increased in the past decade and several bacterial infections are becoming resistant to the most commonly prescribed antibiotic treatments. Primary care physicians see the bulk of upper respiratory tract infections, including pharyngitis, most of which are self-limiting, and antibiotics have only a minor impact on the course of most of these infections. In addition to resistance concerns, unrestricted antibiotic use has a number of disadvantages, including adverse effects, increased health care costs, and perhaps reinforcing a belief of usefulness in our patients that may not be entirely accurate.
Previous studies have demonstrated that delayed antibiotic prescription reduces antibiotic use without an increase in complications, with little advantage compared with the non-prescription strategy.3 However, the current research by Little et al demonstrates that although in most cases an antibiotic is not needed; delayed antibiotic prescription and no antibiotic prescription do not have comparable outcomes. If an antibiotic prescription is being considered, a delayed antibiotic prescription strategy is likely to provide at least a reduction in complications similar to an immediate antibiotic prescription, and perhaps with a reduced rate of revisits. The study also demonstrates that suppurative complications are relatively uncommon in primary care, although it remains difficult to predict who will develop those.
In summary, for patients presenting with typical acute sore throat, it is prudent to utilize a widely accepted clinical decision tool such as the Centor criteria to conduct initial clinical evaluation and further testing.5 However, when a decision to prescribe an antibiotic is anticipated, the current study suggests that a strategy to utilize the delayed antibiotic treatment approach may also further the goal of addressing antibiotic resistance concerns.