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Three Part Question

In [an adult with acute sore throat caused by an unknown organism] is [penicillin V or cephalosporin] more effective at [reducing duration of symptoms]?

Clinical Scenario

A 24 year old man presents with a sore throat, anterior cervical lymphadenopathy, fever and tonsillar exudates. He is prescribed penicillin V but the SHO wonders if cephalosporin would be more effective?

Search Strategy

Medline 1966 to June Week 1 2005
Embase 1980 to 2005 Week 24
Cinahl Cumulative Index to Nursing & Allied Health Literature 1982 to June Week 1 2005
The Cochrane Library Issue 2 2005
{Exp PHARYNGITIS/ OR exp LARYNGITIS/ OR exp TONSILLITIS/ OR exp Peritonsillar Abscess/ OR pharyngitis.af. OR laryngitis.af. OR tonsillitis.af. OR (peritonsillar adj5 abscess).af. OR quinsy.af. OR (throat adj5 infection$) OR (sore adj5 throat$) OR exp Infectious Mononucleosis/ OR (infectious adj5 mononucleosis).af. OR (glandular adj5 fever).af.} AND {phenoxymethylpenicillin.mp. OR exp Penicillin V/} AND {cephalosporin.mp. OR exp CEPHALOSPORINS/} limit to (humans and English language)

Search Outcome

Medline-66 papers found, 1 relevant
Embase 271 papers found-no extra relevant papers
Cinahl-1 paper found-irrelevant
Cochrane-1 systematic review containing 1 relevant trial, however the results were included in a meta-analysis which contained irrelevant trials. Therefore i have included the trial separately.
1 list of abstracts containing 1 relevant trial.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Howe RW, Millar MR, Coast J et al 1997 UK	154 patients were recruited from 39 GP's in 22 practices. Patients aged 16-60 presenting to the GP with sore throat, for whom the GP would normally prescribe an antibiotic were included. The GP recorded the signs present in the throat and took a throat swab Medication was determined by random allocation using blocks of 6, the GP was blinded to the medication. 103 patients returned the symptom diary and could be included. 40 were randomized to`penicillin, 29 to cefixime and 34 to placebo. penicillin-no improvement compared with placebo. Cefixime not statistically significantly different from penicillin. lowest for cefixime	RCT	Symptom resolution on day 3, mean difference in symptom score	penicillin 3.53, cefixime 5.61 not statistically significant (although when cefixime was compared with placebo there was statistical significance unlike penicillin compared with placebo which had no statistical significance)	Comprehensive records of patients eligible for the trial but who were not included were not kept. Non responders were not significantly different to responders although numbers were small. Some of the results were missing. The results were not statistically significant.The author states that an estimated of 60 patients in each arm of the trial would be required to calculate a p value.
			Proportion of patients using analgesia at day 3	45% penicillin, 31% cefixime p=0.013

Comment(s)

This was the only trial found that compared penicillin V and cephalosporin in patients with an unknown organism. The results were not statistically significant so no conclusions can be drawn however cephalosporin seemed to be more effective. Larger trials are needed to confirm this. There are many other trials which compare the two in confirmed GABHS positive patients, which have found cephalosporin to be more effective.

Clinical Bottom Line

Cephalosporin seems to be more effective in pharyngitis patients with an unconfirmed infective agent.

References

1. Howe RW, Millar MR, Coast J et al A randomized controlled trial of antibiotics on symptom resolution in patients presenting to their general practitioner with a sore throat British Journal of General Practice 1997, 47 280-4