Penicillin helps relieve sore throats

Antibiotics: yes or no?

The case A 23-year-old medical student presents with an extremely severe sore throat that has lasted for two days. She is in good general condition and has no fever. The throat shows a pronounced reddening, the tonsils are questionable and not distorted. Two tender lymph nodes on the right can be felt. There is no cough. The patient insists that an antibiotic should be prescribed - on the one hand because of the severe pain, on the other hand because she fears complications.

Should a throat swab be done?

Should an antibiotic be prescribed and if so, which one?

What other therapy is recommended?

Approx. 50 - 80% of pharyngitis are caused by viruses, in a third no pathogen can be detected. Beta-hemolytic streptococci of group A (GAS) are isolated in only about 15-30%. But there are asymptomatic carriers. GAS pharyngitis has an incidence peak in 5- to 15-year-olds. GAS pharyngitis also have a very high tendency to spontaneously heal [5].

Procedure in practice

For everyday practice, a decision rule must be as simple and concise as possible. The Centor score (Fig. 1) can be used to clinically estimate the likelihood of an infection with group A streptococci (GAS) [2].

A Throat swab for a rapid test or culture should only be performed if the result influences the decision for or against antibiotic therapy. Rapid tests for GAS antigen have a specificity of 95% compared to the culture, while the sensitivity of 70 - 90% is significantly lower [3]. In the above case, the center score is 2, i.e. H. the probability of GAS in the smear is only about 15%.

To the question "Antibiotic: yes or no?" the guideline suggests an algorithm (Fig. 2). A throat swab is justifiable with such a mean score. In our case it is negative. If an antibiotic is considered clinically useful, which is not the case in our patient, penicillin would be the first choice and treatment for seven days would be sufficient [9]. The medical student refrains from antibiotics and recommends sage pastilles and paracetamol.

In many patients with Desire for antibiotics if there is a misunderstanding, you actually want pain therapy [8]. The effect of antibiotics is moderate at best, but somewhat more pronounced in the case of clinical signs of GAS pharyngitis. For patients with a sore throat and three Centor criteria, an NNT (number of necessary treatments) of 5 - 6 for an absence of symptoms on the third day of treatment can be assumed for oral penicillin treatment. The duration of the illness is shortened by 1–1½ days [5, 9]. With additional evidence of GAS, an NNT of 4 for oral penicillin treatment can be assumed for the sore throat to subside on the 3rd day of treatment.

Is GAS pharyngitis not treated with antibiotics risky?

Non-purulent complications are acute rheumatic fever (ARF) and acute post-streptococcal glomerulonephritis (APSGN) [4]. The ARF has become extremely rare in industrialized countries, so that the prevention of the ARF is currently not an argument in favor of an antibiotic prescription. There is no evidence that antibiotics can prevent APSGN. Most cases are asymptomatic with microhematuria and heal unnoticed. Routine urine testing after streptococcal infections is therefore no longer recommended.

Which symptomatic therapy?

Paracetamol or ibuprofen relieve sore throats [1, 6]. There is no proof of benefit for many home and natural remedies or over-the-counter drugs. Non-specific measures such as drinking a lot, gargling with salt water or tea, sucking non-medicinal candy or neck wraps can be recommended with reservations. Medicated lozenges, gargle solutions, and throat sprays containing local antiseptics and / or local anesthetics are not recommended. Local antiseptics only work on the surface, while the infection takes place deep down [7]. Herbal and homeopathic remedies can be recommended with restrictions if there is a pronounced desire for therapy or if the effectiveness of better documented symptomatic measures is not sufficient.

1. Burnett I, Box B, Sanner K et al. Onset of analgesia of a paracetamol tablet containing sodium bicarbonate: Adouble-blind, placebo-controlled study in adult patients with acute sore throat. Clin Ther. 2006; 28: 1273-8.
2. Centor RM, Witherspoon JM, Dalton HP, et al. The Diagnosis of Strep Throat in Adults in the Emergeny Room. Med Decision Making 1981; 1: 239-46.
3. Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev 2004; 17: 571-80.
4. Lamagni TL, Efstratiou A, Vuopio-Varkila J, et al. The epidemiology of severe streptococcus pyogenes associated disease in Europe. Euro Surveill 2005; 10: 179-84.
5. Spinks A, Glasziou PP, Del Mar C. Antibiotics for sore throat. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No .: CD000023. DOI: 10.1002 / 14651858.CD000023.pub3.
6. Thomas M, Del Mar C, Glasziou P. How effective are treatments other than antibiotics for acute sore throat? Brit J Gen Pract 2000; 50: 817-20.
7. How long will there be unnecessary throat therapeutics? drug telegram 2002; 33: 107
8. van Driel ML, De Sutter A, Deveugele M, et al. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med. 2006; 4: 494-9.
9. Zwart S, Sachs APE, Ruijs GJHM et al. Penicillin for acute sore throat: randomized double blind trial of seven days versus three days treatment or placebo in adults. BMJ 2000; 320: 150-54.

Prof. Dr. med. Jean-Francois Chenot, MPH
General Medicine Department
Dr. med. Hannelore Wächtler
General Practitioner - Psychotherapy