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Clinical score cuts antibiotic use for sore throats ‘by 30%’

GPs using a new clinical score to target antibiotic treatment in patients with sore throats use less antibiotics and their patients have quicker symptom resolution, when compared with delayed prescribing a UK study has shown.

Use of the five-item FeverPAIN score to decide whether to prescribe patients with an antibiotic immediately or to give them a delayed prescription reduced antibiotic use by almost 30%, compared with simply offering a delayed prescription.

Despite using fewer antibiotics, patients in the clinical score group experienced a greater average improvement in symptoms.

But the use of an in-practice rapid antigen test in conjunction with the FeverPAIN score did not result in any further reductions in antibiotic use or improvements in symptoms.

The researchers said the findings show that using a clinical score can target antibiotics more effectively and help GPs to persuade patients antibiotics are not needed.

They also believe the FeverPAIN score – which comprises fever in the past 24 hours, purulence, rapid (within three days) attendance, inflamed tonsils and no cough or cold symptoms – should enable better targeting of antibiotics than the Centor score currently recommended by NICE, as it allows GPs to rule out likely streptococcal infection in more patients.

The team – headed by researchers at University of Southampton – compared use of the FeverPAIN clinical score, with or without rapid antigen testing, with a straight delayed prescription approach in a study of 631 patients aged three years and older with an acute sore throat.

GPs using FeverPAIN prescribed antibiotics immediately if the patient had four or five of the clinical features, while a delayed antibiotic prescription was offered to patients with two or three features and no antibiotics to those with only one or no features.

The clinical score led to a 29% relative reduction in antibiotic use compared with the straightforward delayed prescription approach, in which patients were told to pick up a prescription three to five days later if their symptoms did not settle or got worse.

Patients in the clinical score group reported greater improvements in their symptoms two to four days after the consultation, such that one in three patients rated their sore throat a slight, rather than moderately bad, problem. Moderately bad or worse symptoms also resolved faster in the clinical score than the delayed prescription group.

In the third group of patients, use of a rapid antigen test for group A streptococci as well as the FeverPAIN score did not offer any further improvements, with a 27% reduction in antibiotic use as well as similar improvements in patients’ symptoms.

The authors concluded: ‘Clinicians can consider using a clinical score to target antibiotic use for acute sore throat, which is likely to reduce antibiotic use and improve symptom control. There is no clear advantage in additional use of a rapid antigen test.’ 

Co-author Dr Michael Moore, a GP in Salisbury and a reader in primary care research at the University of Southampton, told Pulse: ‘We have shown if you use a targeted approach you can further reduce antibiotic prescribing relative to an efficient prescribing strategy – and also give some symptom benefit.’

He added: ‘In theory you would only get reduction in symptoms if there is a bacterial infection in the throat – and if you select those at the highest risk of streptococcal infection then it’s more targeted at the people who are most likely to get symptom benefit.’ 

Dr Moore said the researchers have found in other analyses that the FeverPAIN score picks up bacterial throat infections more accurately than the Centor score – likely because it is based on symptoms from streptococcal group C and G infections as well as group A infections and picks up larger numbers of patients who are at low risk of streptococcal infection.

Dr Dermot Ryan, a GP in Loughborough and former chair of the Primary Care Respiratory Society said: ‘I think [the approach] of using a score based on symptoms  gives a note of reassurance to the patient, because a structured approach has been taken and a clear plan of action provided – and the patient isn’t expected to make the final decision.’

‘The fact that it makes patients feel better on its own means there must be some extra ingredient that gives the patient some extra reassurance, for whatever reason,’ Dr Ryan added.

BMJ 2013; available online 10 October