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Three Part Question

[In patients with acute pharyngitis] is [treatment with antibiotics compared to symptomatic therapy] effective in [reducing incidence of sore throat, fever, acute glomerulonephritis, and rheumatic fever in the primary care setting]?

Clinical Scenario

A 24-year-old healthy male presents to the Emergency Department with a two-day history of sore throat. He does not complain of cough or other respiratory symptoms. On examination he is feverish (38°C), with exudate on his tonsils and tender cervical lymph nodes. His sister had been seen the day before (by a different doctor) with the same symptoms and was prescribed antibiotics immediately.

Search Strategy

Medline 1966-05/18 using PubMed, CINAHL, Cochrane Library (2018), and Embase
[(Pharyngitis/drug therapy"[MAJR]) AND (exp antibiotics)]. LIMIT to English language.

Search Outcome

255 studies were identified; one systematic review from the Cochrane library addressed the clinical question. This review, published in 2013, analyzed 27 trials with a combined total of 12,835 participants. One prospective cohort study has been published that was not included in the meta-analysis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Sprinks et. al 2013 United Kingdom	27 RCTs met inclusion criteria (12,835 patients)	Systematic Review	Primary Outcomes: incidence of sore throat at day 3 and day 7	Antibiotics shorten the duration of pain symptoms by one day on average. The number needed to treat to prevent one sore throat at day three was less than six; at week one it was 21.	There were only 2 case reports of rheumatic fever. There were very few recent trials included in the review, hence it is unclear if changes in bacterial resistance in the community may have affected the effectiveness of antibiotics.
			Secondary Outcomes: acute glomerulonephritis, rheumatic fever, quinsy, otitis media	Antibiotics reduced acute rheumatic fever by more than two-thirds within one month (risk ratio 0.27); antibiotics also reduced the incidence of acute otitis media (RR 0.30); acute sinusitis within 14 days (RR 0.48); and quinsy within two months (RR 0.15) compared to those taking placebo.
Little P et al. 2014 United Kingdom	12,829 adult patients who presented with an acute illness < 14 days of sore throat or who had an abnormal pharynx on examination.	Prospective Cohort Study	Primary Outcome: new clinical diagnosis of otitis media, sinusitis, quinsy, cellulitis or impetigo in the 1 mo following documented presentation of sore throat	Both immediate and delayed antibiotics resulted in decreased suppurative complicationsCompared with no antibiotic prescription, antibiotic prescription was associated with fewer complications (adjusted risk ratio 0.62); estimated number needed to treat was 193	Confounding by indication, unblinded, nonconsecutive enrollment of patients, no non-suppurative complications of post streptococcal glomerulonephritis or rheumatic fever were recorded.
			Secondary Outcome: reconsultation with or development of a new respiratory diagnosis in the month following index presentation	The risk of reconsultation was also reduced by antibiotic prescription (adjusted risk ratio 0.83); estimated number needed to treat was 40. Delayed antibiotic prescription was likely to provide the same reduction in complications with reduced reconsultation rate (NNT 18)

Comment(s)

Strep Pharyngitis is commonly treated with antibiotics to prevent future complications as well as for symptomatic relief. These studies, a prospective cohort study and systematic review, both indicate that there is likely a benefit to antibiotics in reduction of fever, sore throat, acute glomerulonephritis, and rheumatic fever. However, the absolute benefits are modest. Protecting pharyngitis patients against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to benefit. In general, antibiotics shorten the duration of symptoms by about 16 hours.

Clinical Bottom Line

The effect of antibiotics in adults with acute pharyngitis is modest. Clinicians must judge with individual cases whether it is clinically justifiable to employ antibiotics to protect sore throat sufferers against suppurative and non-suppurative complications. In those parts of the world where acute rheumatic fever is common, the number needed to treat may be much lower for antibiotics to be considered effective.

References

1. Spinks A, Glasziou PP, Del Mar CB Antibiotics for sore throat. Cochrane Database Syst Rev 2013 Nov 5;(11):CD000023
2. Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Delaney B, Campbell J, Broomfield S, Barratt P, Hood K, Everitt H, Mullee M, Williamson I, Mant D, Moore M; DESCARTE investigators Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study Lancet Infect Dis 2014 Mar;14(3):213-9.