5.1 Antibiotics in acute sore throat

In the UK, the significance of the presence of bacterial pathogens in cases of sore throat remains in doubt³⁷ (see section 3). It is therefore illogical to treat all sore throats with antibiotics and there is a favourable outcome in the majority of cases even when antibiotics are withheld.

An open study of prescribing strategy in over 700 patients randomised to antibiotic vs. no prescription vs. delayed prescription for three days showed no difference in the main outcomes.³⁸ It is important to note that the following exclusion criteria were applied to entry to the trial: other explanations of sore throat, very ill, suspected or previous rheumatic fever, multiple attacks of tonsillitis, quinsy, or pregnancy. Evidence level Ib

Even if the sore throat persists, a throat swab to identify group A beta-haemolytic streptococcus (GABHS) may not be helpful, as the poor specificity and sensitivity of throat swabs limit their usefulness (see section 3.2). Nevertheless, randomised controlled trials of antibiotic therapy in patients with acute sore throat in whom GABHS has or has not been isolated (whether or not causative) have been reported and these are summarised in Annex 4.

The limited information available is insufficient to support a recommendation on the routine use of antibiotics in acute sore throat.

In severe cases, where the practitioner is concerned about the clinical condition of the patient, antibiotics should not be withheld. (Penicillin V 500 mg, four times daily for 10 days is the dosage used in the majority of studies.)

Practitioners should be aware that infectious mononucleosis may present with severe sore throat with exudate and anterior cervical lymphadenopathy, and should avoid prescription of ampicillin-based antibiotics, including co-amoxiclav, as first line treatment.

5.2 Antibiotics in recurrent sore throat

When sore throat recurs in patients who have received antibiotic treatment, the reasons may include inappropriate antibiotic therapy, inadequate dose or duration of previous therapy, patient non-compliance/non-concordance, re-infection, and local breakdown of penicillin by beta-lactamase producing commensals.^{39, 40} Benzathine penicillin,⁴¹ cefuroxime⁴² and clindamycin^{43, 44} have been shown to be superior to penicillin V in the management of children with this problem, and may reduce the frequency of episodes. Evidence level Ib and III

The possible hazards of clindamycin must be weighed against its efficacy in the treatment of sore throat in patients in whom GABHS has been isolated. It may be considered as an alternative to surgery in those in whom surgery is contraindicated or in those who do not wish to have the operation.

There is no evidence to support a recommendation on the use of antibiotics in recurrent non streptococcal sore throat.

5.3 Use of antibiotics to prevent rheumatic fever and glomerulonephritis

It has been contended that the primary clinical rationale for treating streptococcal pharyngitis with antibiotics is the prevention of rheumatic fever and other sequelae, and that outbreaks of rheumatic fever are still being reported in both children and adults in the United States.⁴⁵ This does not apply in the UK, and a small reduction in bacteriological failure rate has to be weighed against the considerable increase in cost when antibiotics other than penicillin are used.⁴⁶ The incidence of rheumatic fever in the UK is extremely low and there is no support in the literature for the routine treatment of sore throat with penicillin to prevent the development of rheumatic fever. ⁴⁷ Evidence level IIa

Similar considerations apply to the prevention of glomerulonephritis.⁴⁸ Most of the information on the prevention of acute rheumatism comes from studies performed on military personnel living in overcrowded barracks immediately after the second World War, when the incidence of rheumatic fever was exceptionally high. At that time penicillin, particularly benzathine penicillin, was shown to be an effective prophylactic.⁴⁹ There is no evidence that these results are applicable in modern Britain. Evidence level IIa

Sore throat should not be treated with antibiotics specifically to prevent the development of rheumatic fever and acute glomerulonephritis.

5.4 Use of antibiotics to prevent suppurative complications

Patients with severe pustular tonsillitis are frequently treated with antibiotics both in general practice and in hospital on pragmatic grounds. There is no evidence that the routine administration of antibiotics to individuals with sore throats will reduce the occurrence of suppurative complications such as quinsy. The incidence of quinsy is very low but figures from the Common Services Agency, Information & Statistics Division show it has risen over the last five years. There is no evidence that this is related to changes in the use of antibiotic therapy.

The prevention of suppurative complications is not a specific indication for antibiotic therapy in sore throat.

5.5 Use of antibiotics to relieve symptoms

Although antibiotic therapy has been shown to alleviate symptoms even in sore throats not caused by bacteria,⁵⁰ the superiority of antibiotics over simple analgesics is marginal in reducing duration or severity.^{38, 51} Even in `proven' GABHS infection, the symptomatic improvement following penicillin, although superior to that following simple placebo in some studies,^{52, 53} has been unimpressive in others, especially when compared to simple analgesics.^{54, 55} Evidence level Ib

Antibiotics should not be used to secure symptomatic relief in sore throat.

Even if the symptomatic benefit were more substantial, a single case of penicillin-induced anaphylaxis would be a heavy price to pay.

5.6 Use of Antibiotics to prevent cross-infection in sore throat

No studies of this have been performed in the community setting in the UK. The evidence in favour of the use of antibiotics to prevent cross-infection in sore throat comes mainly from army barracks and other closed institutions and there is no recent evidence from this country. There is no evidence that trying to eradicate GABHS with routine antibiotic therapy for sore throat will produce any measurable health gain in the general public, and some danger in encouraging the emergence of antibiotic resistant strains of other organisms, although GABHS remains sensitive to penicillin despite its widespread use.^{45, 56} An American study has recommended that when GABHS has been identified in children, a full 24 hours of antibiotic treatment should be given before return to school or daycare.⁵⁷ Evidence level IIa

Antibiotics may prevent cross-infection with GABHS in closed institutions (such as barracks, boarding schools) but should not be used routinely to prevent cross-infection in the general community.