Do patients with sore throat benefit from penicillin? A randomized double-blind placebo-controlled clinical trial with penicillin V in general practice.

BACKGROUND: The effect of antibiotic therapy in sore throat is questionable and this dilemma has been complicated by the emergence of multiple resistant strains of micro-organisms. AIM: A randomized double-blind placebo-controlled clinical trial was undertaken in patients aged 4-60 years to assess the efficacy of penicillin V on the clinical course and bacteriological response in patients with sore throat in general practice. METHOD: Two hundred and thirty-nine patients presenting with an acute sore throat to 37 general practices in the Netherlands who were clinically suspected of group A beta-haemolytic streptococci (GABHS) were randomized for treatment with penicillin V (n = 121) or placebo (n = 118). Resolution of sore throat, fever and return to daily activities were evaluated by the general practitioner 2 days after the start of treatment and by the patients keeping a diary for 7 days. The result of throat culture after 2 days was evaluated. RESULTS: A difference in resolution of sore throat was present after 2 days in all patients, but was a result of GABHS-positive patients (n = 111; 46%) in favour of those randomized for penicillin V (adjusted odds ratio 5.3; 95% CI 1.9-15.1). An effect in the course of fever was also seen in GABHS-positive patients (adjusted odds ratio 5.3; 95% CI 1.02-27.7). A difference of 1-2 days was seen in clinical recovery. No difference was found in daily activities between the treatment groups. After 2 days, 4% of the penicillin-treated patients harboured GABHS compared with 75% of the placebo group. CONCLUSION: Only GABHS-positive patients benefit from penicillin V in their clinical cure in the first few days. Therefore, rapid testing is necessary. Treatment may be beneficial with regard to the clinical course, but it is not necessary.     

Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms.

BACKGROUND: Although the vast majority of respiratory tract symptoms are self-limiting, many patients visit their GP for these symptoms and antibiotics are over-prescribed. AIM: To explore determinants of patients visiting GPs for recent cough, sore throat, or earache; for being prescribed antibiotics; and for patients' satisfaction with visiting the GP. Design of the study: Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire. SETTING: A total of 7057 adult patients of 163 GPs in the Netherlands. METHOD: Characteristics of patients and GPs as well as morbidity data were derived from the DNSGP-2 and a health interview. Characteristics of the symptoms, GPs' management and patients' satisfaction were measured by an additional written questionnaire. Data were analysed by means of multivariate logistic regression. RESULTS: About 40% of the responders (n = 1083) reported cough, sore throat, or earache in the 2 weeks preceding the interview and, of them, 250 visited their GP. Of this latter group, 97 patients were prescribed antibiotics. Apart from non-medical reasons, relevant medical factors played an important role in deciding to visit the GP. Smokers and patients with cardiac disease or diabetes mellitus were not especially inclined to see their GP. Smoking behaviour, fever, and views on respiratory tract symptoms and antibiotics of patients and GPs were associated with being prescribed antibiotics. Patients' perception of having been carefully examined was associated with their satisfaction, while receiving antibiotics was not. CONCLUSION: GPs should inform patients with clear elevated risk when to visit their GP in cases of cough, sore throat, or earache. There is still a need for GPs and patients to be better informed about the limited significance of single inflammation signs (for example, fever and green phlegm) as an indication for antibiotics. Careful examination of the patient contributes to patient satisfaction.     

Characteristics of children consulting for cough, sore throat, or earache.

BACKGROUND: GPs are often consulted for respiratory tract symptoms in children. AIM: To explore characteristics of children, their parents, and their GPs that are correlated with consulting a GP for cough, sore throat, or earache. DESIGN OF STUDY: Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire. SETTING: Children aged 0-17 years registered with 122 GPs in Dutch general practice. METHOD: Characteristics of patients and their GPs were derived from the DNSGP-2 health interview and a questionnaire, respectively. Characteristics of the illness symptoms and GP consultation were acquired by means of an additional questionnaire. Data were analysed using multivariate logistic regression. RESULTS: Of all children who completed the questionnaire, 550 reported cough, sore throat, or earache in the 2 weeks preceding the interview with 147 of them consulting their GP. Young children more frequently consulted the GP for respiratory symptoms, as did children with fever, longer duration of symptoms, those reporting their health to be 'poor to good', and living in an urban area. When parents were worried, and when a child or their parents were cued by someone else, the GP was also consulted more often. GP-related determinants were not associated with GP consultation by children. CONCLUSION: This study emphasises the importance of establishing the reasons behind children with respiratory tract symptoms consulting their GP. When GPs are aware of possible determinants of the decision to consult a GP, more appropriate advice and reassurance can be given regarding these respiratory symptoms, which are generally self-limiting.     

Guideline for the management of acute sore throat: ESCMID Sore Throat Guideline Group

The European Society for Clinical Microbiology and Infectious Diseases established the Sore Throat Guideline Group to write an updated guideline to diagnose and treat patients with acute sore throat. In diagnosis, Centor clinical scoring system or rapid antigen test can be helpful in targeting antibiotic use. The Centor scoring system can help to identify those patients who have higher likelihood of group A streptococcal infection. In patients with high likelihood of streptococcal infections (e.g. 3–4 Centor criteria) physicians can consider the use of rapid antigen test (RAT). If RAT is performed, throat culture is not necessary after a negative RAT for the diagnosis of group A streptococci. To treat sore throat, either ibuprofen or paracetamol are recommended for relief of acute sore throat symptoms. Zinc gluconate is not recommended to be used in sore throat. There is inconsistent evidence of herbal treatments and acupuncture as treatments for sore throat. Antibiotics should not be used in patients with less severe presentation of sore throat, e.g. 0–2 Centor criteria to relieve symptoms. Modest benefits of antibiotics, which have been observed in patients with 3–4 Centor criteria, have to be weighed against side effects, the effect of antibiotics on microbiota, increased antibacterial resistance, medicalisation and costs. The prevention of suppurative complications is not a specific indication for antibiotic therapy in sore throat. If antibiotics are indicated, penicillin V, twice or three times daily for 10 days is recommended. At the present, there is no evidence enough that indicates shorter treatment length.     

Randomized evaluation of benzathine penicillin V twice daily versus potassium penicillin V three times daily in the treatment of group A streptococcal pharyngitis

In a randomized, prospective, multicenter study the clinical and bacteriological efficacies of three dosage schedules with two different salts of oral penicillin V suspensions (regimen 1: potassium salt of penicillin V, 50,000 U/kg of body weight per day in three divided doses; regimen 2: benzathine salt of penicillin V, 50,000 U/kg of body weight per day in two divided doses; and regimen 3: benzathine salt of penicillin V, 100,000 U/kg of body weight in two divided doses) for the treatment of streptococcal pharyngitis were evaluated. Children with clinical signs of acute pharyngitis and a positive throat culture for group A beta-hemolytic streptococci (GABHS) were eligible. There was no difference between the treatment groups with respect to the overall clinical success rate. Eradication of the original serotype of GABHS from throat cultures was achieved in 87.1 % (regimen 1), 85.5 % (regimen 2) and 87.7 % (regimen 3) of patients. The incidence of potential drug-related adverse events was significantly higher in patients treated with regimen 3. The results of this and earlier studies strongly suggest that oral penicillin given twice daily should be the recommended treatment for the initial treatment of pharyngitis due to GABHS. Doubling the total daily dose is not beneficial in the usual clinical setting. Because of its favorable pharmacokinetics, the benzathine salt of penicillin V appears to be well suited for a twice-a-day dosage schedule.The Pharyngitis Study Group included the following pediatricians in private practrice: H.G. Berzel, W. Doering, V. Grosse, W. Hartmann, P. Hirschbrunn, H. Holder, J. Just, A. Kielhorn, C. Kiliccioglu, K. Kneppo, G. Niehaus, J. Reineke, A. Rutsch, C. Sievers, K. Strasser, K.-Y. Tjhen, R. Wartha.     

Towards a better diagnosis of throat infections (with group A beta-haemolytic streptococcus) in general practice.

BACKGROUND: Sore throat is a common complaint in general practice. However, management strategies are not very clear. A better diagnostic procedure is needed to prevent the overuse of antibiotics. AIM: To assess the diagnostic value of a rapid streptococcal antigen detection test in addition to four clinical features in patients with sore throat, using throat culture and antibody titres as reference tests. METHOD: Four clinical features [fever (history) > or = 38.0 degrees C, lack of cough, tonsillar exudate, and anterior cervical lymphadenopathy] were registered in 558 patients aged 4 to 60 years presenting with sore throat of no more than 14 days' duration. A rapid diagnostic test was performed, as well as a throat culture and antibody titres [fourfold increase in anti-streptolysin-O (ASO) and/or anti-deoxyribonuclease B (anti-DNAase B)] in patients aged 11 years and older. RESULTS: Throat cultures were positive for group A beta-haemolytic streptococcus (GABHS) in 33% of the patients. Rapid tests were positive in 24%. Compared with the throat culture, the sensitivity of the rapid test was 65%, the specificity 96%, the positive predictive value 88%, and the negative predictive value 85%. However, for patients with three or four clinical features, the sensitivity of the rapid test was considerably higher at 75%. Children (< or = 14 years) had a slightly raised specificity and raised positive predictive value and prevalence. With the antibody titres as a reference, the rapid test performed as well as the throat culture with regard to its predictive value. CONCLUSION: For the management of patients with sore throat in general practice, a rapid test may have an additional value, especially in patients with a high chance of having GABHS infection. However, as the sensitivity of the test studied is low, tests with a higher sensitivity are needed.     

Flurbiprofen microgranules for relief of sore throat: a randomised,double-blind trial

Background

Many people with sore throat seek, and are often inappropriately prescribed, antibiotics.

Aim

The objective of this study was to determine the analgesic efficacy of flurbiprofen 8.75 mg microgranules versus placebo. These microgranules are a possible alternative treatment for patients with sore throat due to upper respiratory tract infection (URTI).

Design and setting

Randomised, double-blind, placebo-controlled, multiple-dose study conducted at eight primary care sites in Australia.

Method

Participants with sore throat of onset within the past 4 days received either flurbiprofen 8.75 mg microgranules or non-medicated placebo microgranules. Throat soreness, difficulty in swallowing, sore throat pain intensity, sore throat relief, oral temperature, and treatment benefits were all assessed at regular intervals.

Result

Of 373 patients from eight centres, 186 received flurbiprofen 8.75 mg microgranules and 187 received placebo microgranules (intent-to-treat population). Throat soreness was significantly reduced over the first 2 hours after the first dose. Reductions in difficulty in swallowing were observed at all time points from 5 to 360 minutes after the first dose, after taking flurbiprofen microgranules versus placebo. Sore throat relief was also evident at 1 minute and lasted for at least 6 hours. The multiple-dose efficacy results showed reduction of difficulty in swallowing at the end of days 1–3 and sore throat relief at the end of day 1.

Conclusion

Microgranules containing flurbiprofen 8.75 mg provided fast and effective relief from sore throat due to URTI and represent an alternative treatment option to antibiotic therapy.     

Views on respiratory tract symptoms and antibiotics of Dutch general practitioners, practice staff and patients

OBJECTIVES: To explore views on respiratory tract symptoms (cough, sore throat and earache) and antibiotics of GPs, practice staff, and patients. METHODS: In a nationwide study, 181 GPs, 204 practice staff members and 1250 patients from 90 practices participated by answering 14 items relating to views on respiratory tract symptoms and antibiotics in a written questionnaire. Differences in means were compared. RESULTS: Patients more than GPs endorsed the seriousness of respiratory tract symptoms, the need to consult a GP, the need to prescribe antibiotics, and the ability of antibiotics to speed up recovery. GPs were more than patients convinced of the self-limiting character of respiratory tract symptoms and of the fact that antibiotics have side effects. Practice staff took a middle ground in most of these views. CONCLUSIONS: Differences between GPs, practice staff and patients must be taken into account when exploring patients' complaints and advising on treatment. Education and knowledge programmes for practice staff might be advocated.     

Five days of erythromycin estolate versus ten days of penicillin V in the treatment of group a streptococcal tonsillopharyngitis in children

In a randomized, prospective, multicenter trial, 227 children ranging in age from 3 to 17 years who had tonsillopharyngitis and a throat culture positive for group A beta-hemolytic streptococci (GABHS) were treated with erythromycin estolate (40 mg/kg/d in two divided doses for five days) or penicillin V (30 mg/kg/d in three divided doses for ten days). Clinical signs and symptoms of tonsillopharyngitis were recorded, and throat cultures were obtained before treatment as well as one to three days and six weeks after treatment. Clinical success (cure and improvement) was observed on days 6 to 8 in 100 of 102 (98%) assessable children treated with erythromycin estolate and on days 11 to 13 in 97 of 99 (98%) assessable children treated with penicillin V. Of all patients showing clinical success, 11 were rated as improved, all of whom were treated with erythromycin estolate. There was a trend towards increased use of analgesic treatment in the erythromycin estolate group (41 % vs 33%). On completion of treatment, the rate of eradication of GABHS was 83.3% in the erythromycin estolate group compared with 87.9% in the penicillin V group. The difference is not significant but does not take into account patients excluded because of erythromycin resistance (3.7%). Clinical recurrence was observed in 11 (10.8%) patients treated with erythromycin estolate and in 6 (6.1%) patients treated with penicillin V (non-significant difference). Compliance in the erythromycin estolate group was statistically superior to that in the penicillin V group. The incidence and nature of adverse events were similar in both treatment groups.     

Antibiotics, sore throats and acute nephritis

A study was carried out of 274 children in Scotland aged 0 to 13 years recorded as having had acute nephritis over a four-year period (1976-79). The medical records for 223 of the patients were examined and 79 cases of poststreptococcal nephritis were identified, giving an estimated incidence of 2.1 episodes per 100,000 children per year. Using a number of assumptions, the authors sought the answers to two important questions: What is the risk that glomerulonephritis will develop after sore throat/inflamed throat illness? Is this risk influenced by the prescribing of an antibiotic for the original illness?The risks of developing nephritis after an antibiotic-treated sore throat and after a non-antibiotic treated sore throat were assessed as being equivalent (1:13,000 and 1:17,000 respectively). Furthermore, it appears that, during his lifetime, a general practitioner has a chance of only one in six of seeing a child with post-streptococcal nephritis after a sore throat.     

Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study

Background

Management of pharyngitis is commonly based on features which are thought to be associated with Lancefield group A beta-haemolytic streptococci (GABHS) but it is debatable which features best predict GABHS. Non-group A strains share major virulence factors with group A, but it is unclear how commonly they present and whether their presentation differs.

Aim

To assess the incidence and clinical variables associated with streptococcal infections.

Design and setting

Prospective diagnostic cohort study in UK primary care.

Method

The presence of pathogenic streptococci from throat swabs was assessed among patients aged ≥5 years presenting with acute sore throat.

Results

Pathogenic streptococci were found in 204/597 patients (34%, 95% CI = 31 to 38%): 33% (68/204) were non-group A streptococci, mostly C (n = 29), G (n = 18) and B (n = 17); rarely D (n = 3) and Streptococcus pneumoniae (n = 1). Patients presented with similar features whether the streptococci were group A or non-group A. The features best predicting A, C or G beta-haemolytic streptococci were patient’s assessment of severity (odds ratio [OR] for a bad sore throat 3.31, 95% CI = 1.24 to 8.83); doctors’ assessment of severity (severely inflamed tonsils OR 2.28, 95% CI = 1.39 to 3.74); absence of a bad cough (OR 2.73, 95% CI = 1.56 to 4.76), absence of a coryza (OR 1.54, 95% CI = 0.99 to 2.41); and moderately bad or worse muscle aches (OR 2.20, 95% CI = 1.41 to 3.42).

Conclusion

Non-group A strains commonly cause streptococcal sore throats, and present with similar symptomatic clinical features to group A streptococci. The best features to predict streptococcal sore throat presenting in primary care deserve revisiting.     

Quality of life improvement with soy sauce ingredients, Shoyu polysaccharides, in perennial allergic rhinitis: a double-blind placebo-controlled clinical study

Soy sauce (Shoyu) is a traditional fermented seasoning of East Asian countries and available throughout the world. We obtained polysaccharides from raw soy sauce, and showed the anti-allergic activities of these Shoyu polysaccharides (SPS) in vitro and in vivo. The present study determined whether oral supplementation of SPS is an effective intervention for patients with perennial allergic rhinitis. In a 4-week randomized, double-blind, placebo-controlled parallel group study, patients with mild perennial allergic rhinitis were treated with 600 mg of SPS (n=11) or placebo (n=10) each day. After 4 weeks of treatment with SPS, a reduction in symptom scores for runny nose, sore throat, and itchy eyes were significantly changed from the baseline within the group (p<0.05), but no change in these scores was observed over 4 weeks of treatment in the placebo group. However, differences in the symptom scores during the study period were not significantly different between the groups. The total symptom score, calculated from the sum of individual scores, showed a significant difference between the 2 groups after 4 weeks of treatment (p<0.05). The efficacy of global symptoms score, which was defined as the adjusted mean change from baseline during 4 weeks of treatment, also showed a significant improvement in the SPS group (p<0.05). An overall evaluation of the medication's effectiveness after 4 weeks treatment showed significant differences between the SPS- and placebo-treated groups (p<0.05). In conclusion, SPS of soy sauce improved the quality of life for patients with perennial allergic rhinitis, and soy sauce would be useful in an anti-allergic therapy utilizing everyday foods.     

Comparison of the Directigen 1-2-3 Group A Strep Test with culture for detection of group A beta-hemolytic streptococci.

The Directigen 1-2-3 Group A Strep Test (DGAST; BBL Microbiology Systems, Cockeysville, Md.) was compared with conventional culture procedures on Trypticase soy agar with 5% sheep blood (BBL) and Selective Streptococcal Agar (ssA; BBL) for detection of group A beta-hemolytic streptococci (GABHS) for 1,006 patients complaining of sore throat. The DGAST was performed at five acute-care clinics according to the instructions of the manufacturer; interpretation of the cultures was done at the central microbiology laboratory. Of 924 patients with complete data, 243 (26.3%) were positive for GABHS on culture when both sheep blood agar and ssA were used. Of the patients with positive cultures, 159 were detected by the DGAST, yielding a sensitivity of 65.4%, a specificity of 84.7%, a positive predictive value of 60.5%, and a negative predictive value of 87.3%. The greater the number of colonies on culture, the greater the sensitivity of the DGAST, and the more intense the positive reaction on the DGAST, the higher the positive predictive value of the test. For the identification of GABHS, sheep blood agar was superior to ssA by 12.9% at 24 h and by 3.4% at 48 h of incubation.     

An analysis of referral patterns for dizziness in the primary care setting.

BACKGROUND: The majority of balance disorders are non life-threatening and symptoms will resolve spontaneously. However, some patients require further investigation and many disorders may benefit from specialist treatment it is unclear whether appropriate identification and referral of this group of patients presently occurs. AIM: To review the management of patients with symptoms of dizziness within primary care. METHOD: A retrospective review of the management of 503 patients who visited their general practitioner (GP) complaining of dizziness between August 1993 and July 1995. Management was then compared with local criteria. RESULTS: On average, 2.2% of patients per year at the practices studied consulted their GP about dizziness, amounting to 0.7% of all consultations. The most common GP diagnosis was of an ear, nose, and throat (ENT) disorder (33.8%). Similarly, many of the 16% referred were directed to ENT (36%) specialists. The proportion of patients referred was significantly higher in those seeing their GP at least twice, those with symptoms lasting a year or more, or where there were additional symptoms associated with the dizziness, indicative of a cardiac, ENT, or neurological disorder. Compared with the local criteria, 17% of management decisions were deemed inappropriate. The major failing was not referring appropriate patients. This group comprised patients with chronic, non-urgent symptoms, and were significantly older than those appropriately referred. CONCLUSION: Patients with chronic symptoms of dizziness, particularly the elderly, are under-referred for specialist consultation and, therefore, do not have access to appropriate treatment regimes. This suggests a need for further training of GPs and evaluation of therapeutic needs of elderly dizzy patients.     

Role of Nasopharyngeal Culture in Antibiotic Prescription for Patients with Common Cold or Acute Sinusitis

The aim of the present study was to assess the hypothesis that, when present in nasopharyngeal secretions, Streptococcus pneumoniae. Haemophilus influenzae, and Moraxella catarrhalis play a pathogenic role early in the course of an upper respiratory tract infection. Adults with a clinical diagnosis of acute sinusitis or common cold were enrolled. Participants were randomly assigned in a double-blind manner to receive azithromycin 500 mg daily or placebo for 3 days. The effect of treatment on symptom evolution in the predefined subset of patients with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis in their nasopharyngeal secretions was assessed. Of 265 patients enrolled, 132 received placebo and 133 azithromycin. Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis was identified in nasopharyngeal secretions of 77 patients (29%). In this predefined subgroup of patients with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, resolution of symptoms by day 7 occurred in 73% of those treated with azithromycin compared with 47% of those who received placebo (P=0.007). The median time before resolution of symptoms was 5 days in the azithromycin group compared to 7 days in the placebo group. Respiratory complications requiring antibiotic treatment occurred in 19% of patients in the placebo group and in 3% of the azithromycin group (P=0.025). In the remaining 188 patients without Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, resolution of symptoms by day 7 was similar in both groups (69% in the placebo group vs. 64% in the azithromycin group [P=0.75]). Antibiotic treatment is of clinical benefit for patients with acute sinusitis or common cold when Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis is present in nasopharyngeal secretions. This observation provides new insights into the pathogenic role of these bacteria in the early stage of the common cold.     

Primary care group commissioning of services: the differing priorities of general practitioners and district nurses for palliative care services.

BACKGROUND: General practitioners (GPs) have become more responsible for budget allocation over the years. The 1997 White Paper has signalled major changes in GPs' roles in commissioning. In general, palliative care is ranked as a high priority, and such services are therefore likely to be early candidates for commissioning. AIM: To examine the different commissioning priorities within the primary health care team (PHCT) by ascertaining the views of GPs and district nurses (DNs) concerning their priorities for the future planning of local palliative care services and the adequacy of services as currently provided. METHOD: A postal questionnaire survey was sent to 167 GP principals and 96 registered DNs in the Cambridge area to ascertain ratings of service development priority and service adequacy, for which written comments were received. RESULTS: Replies were received from 141 (84.4%) GPs and 86 (90%) DNs. Both professional groups agreed that the most important service developments were urgent hospice admission for symptom control or terminal care, and Marie Curie nurses. GPs gave greater priority than DNs to specialist doctor home visits and Macmillan nurses. DNs gave greater priority than GPs to Marie Curie nurses, hospital-at-home, non-cancer patients' urgent hospice admission, day care, and hospice outpatients. For each of the eight services where significant differences were found in perceptions of service adequacy, DNs rated the service to be less adequate than GPs. CONCLUSION: The 1997 White Paper, The New NHS, has indicated that the various forms of GP purchasing are to be replaced by primary care groups (PCGs), in which both GPs and DNs are to be involved in commissioning decisions. For many palliative care services, DNs' views of service adequacy and priorities for future development differ significantly from their GP colleagues; resolution of these differences will need to be attained within PCGs. Both professional groups give high priority to the further development of quick-response clinical services, especially urgent hospice admission and Marie Curie nurses.