Antibiotics are overprescribed
3-10 OPEN RANDOMIZED TRIAL OF PRESCRIBING STRATEGIES IN MANAGING SORE THROAT

"Although recent guidelines advocate using results from throat swabs—or clusters of symptoms or signs—to determine which patients should be given antibiotics, management is still controversial. Throat swabs have poor validation characteristics, are expensive, and may not alter prescribing decisions." The largest primary care trial found that antibiotics did not shorten the duration of symptoms.
By more closely approximating everyday practice, open trials provide important evidence of effectiveness. They are essential when outcome measures include patient’s perceptions and choices in response to different strategies—for example, whether delayed prescriptions are collected, the perceived efficacy of antibiotics, and the likelihood of future attendance when symptoms have resolved without treatment.
This study assessed 3 strategies for sore throat.
Conclusion: Antibiotics only marginally affected the resolution of symptoms.

STUDY

1. 1. Entered over 700 patients age 4 and over. All had sore throat and an abnormal sign in the throat (inflamed tonsils or pharynx, purulent exudate, faucial or palatal inflammation, cervical adenopathy).
2. 2. Excluded patients who were very ill (when not giving antibiotics might be unethical) had suspected or previous rheumatic fever, had had multiple attacks of tonsillitis, had severe local symptoms (quinsy), or who were pregnant.
3. 3. Randomized to: 1) Antibiotics (penicillin V or erythromycin if allergic to penicillin) for 10 days, or 2) No antibiotic prescribed, or 3) Given a prescription for antibiotic to use if symptoms were not starting to settle within 3 days.

RESULTS

2. Most of those receiving the delayed prescription did not use it.

3. 87% of patients in antibiotic group thought antibiotics were effective. Most intended coming to the doctor in future attacks. Legitimization of illness-—to explain to work or school or family or friends—was an important reason for consultation.

4. Patients who were more satisfied got better more quickly. Satisfaction related strongly to how well the doctor dealt with patient’s concerns.

DISCUSSION

1. The trial excluded very ill patients (not defined) and could not show the efficacy of antibiotic prescribing strategies for them. Nevertheless, the trial considered the large group for which general practitioners might prescribe (or withhold) antibiotics.
2. The small differences between groups suggests that antibiotics only marginally affect resolution of symptoms.
3. "Throat swabs are neither sensitive nor specific for serologically confirmed infection, considerably increase costs, may medicalize illness, and alter few management decisions."
4. The net symptom burden is unlikely to be significantly improved by prescribing antibiotics for patients who are not very ill.
5. Legitimization of of illness—where the doctor provides gate keeping to the sick role—is an important factor in attending the doctor.
6. Prescribing antibiotics resulted in more patients who were very satisfied with the consultation. Some patients have considerable expectations from antibiotics. Satisfaction in this study predicted duration of illness and was closely related to dealing with patients concerns. Satisfaction predicts compliance. The doctor’s approach to the consultation affects the patients recovery. More effective doctor-patient communication improves health outcomes.

CONCLUSION
For most patients presenting to their general practitioner with sore throats, antibiotics only marginally affect the resolution of symptoms.
Even after one consultation, prescribing antibiotics significantly enhances belief in antibiotics and intention to consult in the future. Legitimization of illness in an importance reason why people attend their general practitioner. Satisfaction is strongly related to effective management of patients concerns.
Therefore, unless patients with sore throat are very ill, doctors should consider exploring patient’s concerns and avoid prescribing antibiotics—or offer antibiotics if symptoms persist for a few days. Immediate prescription is likely to encourage the medicalization of a self limiting illness without altering the extent and duration of symptoms.

BMJ March 8, 1997; 314: 722-27 Original investigation, from Southampton University, Southampton, UK

Comment:
No doubt many patients with acute sinusitis and sore throat would recover just as quickly without antibiotic therapy. No doubt antibiotics are over prescribed—leading to increased costs, adverse effects and antibiotic resistance. I believe the skillful clinician and a reasonable patient (after receiving full information and after the physician asks for and listens to concerns) can concur in a treatment regimen. I believe the skillful clinician can identify those who are very ill.
The "if" (delayed) prescription is a welcome compromise—many will not get it filled.
The clinician must always deal with the specter of rheumatic fever and glomerulonephritis. This tilts clinicians toward prescribing antibiotics. (See the following abstract.)
Clinicians must balance patient’s concerns with obligations to society (reducing the likelihood of widespread antibiotic resistance).
What if a patient insists on antibiotics? The doctor cannot say with absolute certainty in an individual that antibiotics therapy will be futile. I suspect that most clinicians would go along. Again, the "if" prescription may be a compromise. RTJ

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