Sore Throat in Adults – Does the Introduction of a Clinical Scoring System Improve the Management of These Patients in a Secondary Care Setting?

Abstract

Objective: To audit sore throat management in adults, introduce proforma-based guidelines and to reaudit clinical practice.

Setting: Adult emergency department of an inner city teaching hospital.

Methods: A literature search was carried out to identify relevant guidelines. In stage one, patients presenting to the emergency department with sore throat were identified retrospectively from the emergency department attendance register. Proformas were completed retrospectively. In stage two, new guidelines were introduced and staff educated about the guidelines. In stage three, patients presenting with sore throat were identified at triage and proformas were completed at time of consultation.

Outcome Measures: (1) appropriate clinical assessment of the likelihood of bacterial infection using the clinical scoring system, (2) appropriateness of antibiotic prescription, (3) recommendation of supportive treatments to patients.

Results: Introduction of a clinical scoring system reduced the inappropriate prescribing of antibiotics from 44 per cent to 11 per cent. Correct antibiotic prescription rose from 60 per cent to 100 per cent. Although the variety of advice given about supportive treatment increased, the actual number of patients receiving documented supportive advice fell from 67.8 per cent in stage one to 58 per cent in stage three.

Conclusion: The introduction of clinically based guidelines for the diagnosis and management of sore throat in adults can reduce inappropriate antibiotic prescribing.

Key words: Adult; Sore Throat; Management; Antibiotics

Introduction

Usually a self-limiting disease, acute pharyngitis accounts for 1 to 2 per cent of all visits to outpatient departments, general practitioners (GP) and emergency departments (ED).1 Although in adults a wide variety of infectious agents may cause pharyngitis, the majority are viral. Group A β-haemolytic streptococcus is only responsible for 5 to 15 per cent of cases.2,3,4 Despite its high incidence, there is no consensus on the optimum management strategy for patients presenting with acute pharyngitis. Current management guidelines vary in their recommendations on antibiotic prescribing and the need for the laboratory confirmation of Group A- haemolytic streptococcus.5-12

In the ED, the diagnosis and management of pharyngitis is primarily clinical as the results of commonly used investigations (throat swabs and rapid antigen tests (RAT)) are not readily available. An initial audit performed in the ED demonstrated that a large percentage of patients presenting with pharyngitis were treated inappropriately with antibiotics. This study sought to identify and implement clinically based guidelines that would reduce inappropriate prescription of antibiotics.

Methods

This was a retrospective proforma audit carried out in the adult ED of an inner city teaching hospital, with an annual attendance of 55 000 patients. A literature search was carried out on MEDLINE and EMBASE using the keywords ‘sore throat’, ‘adult’, ‘guidelines’ and ‘antibiotics’. The retrieved papers were critically appraised and the guidelines most relevant to UK practice were chosen for this study. The American Academy of Physicians Guidelines7 were chosen for this study because they are clinically based guidelines and are most appropriate for the ED setting, being similar to the original Centor Scoring System,6 a clinical scoring system which was devised for the ED. Validated in several populations,7,8,9,10 this score uses four criteria to determine the likelihood of Group A- haemolytic streptococcus infection in patients presenting with a sore throat: absence of cough, history of fever or a measured temperature of ≥ 38.0C, tonsillar exudate, and tender anterior cervical lymph nodes. If two or fewer criteria are present, no antibiotic therapy is required. If three or four criteria are present then penicillin V (or erythromycin) should be prescribed. The actual risk of Group A-haemolytic streptococcus is dependent upon the prevalence of Group A-haemolytic streptococcus in the population (unknown in this setting).

The study period was divided into three stages. Stage one lasted four months during which time all patients presenting with sore throat were identified retrospectively by searching the ED attendance register for patients presenting with sore throat, pharyngitis or tonsillitis. Stage two lasted one month and involved disseminating information to both medical and nursing staff about the Centor Score to be used in stage three. In addition to staff tutorials, the scoring system was displayed in prominent areas within the department and incorporated into the ED Guidelines on the hospital intranet (www.ubht.nhs.swest.uk/EDhandbook). In stage three, which lasted five months, patients presenting with sore throat, pharyngitis or tonsillitis were identified by the triage nurse and a proforma was attached to their ED card (Appendix 1). This was completed by the healthcare professional at the time of consultation.

Patients were excluded from stage one if they had insufficient information on the ED card to enable a Centor Score to be calculated. Exclusion criteria for stage three included patients with chronic or recurrent sore throat, immunocompromise, pregnancy, epidemic pharyngitis, a history of rheumatic fever or valvular heart disease.9

TABLE I

STAGE ONE OF THE AUDIT

Data was collected using a proforma for stages one and three. In phase one, the notes were analysed and the proforma filled in retrospectively by JB. In the third stage, the proforma, attached to the notes of all patients presenting with a sore throat, pharyngitis or tonsillitis, was completed by the treating physician and analysed by JB.

Three outcome measures were looked at:

(1) Appropriate clinical assessment of the likelihood of bacterial infection using the Centor Score

(2) Appropriate antibiotic prescription – penicillin V or erythromycin

(3) Recommendation of supportive treatments (e.g. paracetamol, ibuprofen or topical anaesthesia) to patients

Results

Sixty-eight patients presenting to the ED with sore throat, pharyngitis or tonsillitis were identified during the study period. Nine patients were excluded from stage one because there was insufficient documentation to allow a calculation of the Centor Score. Consequently, 28 patients were included in stage one (Table I) of the audit and thirty-one patients were included in stage three (Table II).

In stage one of the study, 18 patients (64.3 per cent) scored a Centor Score of between O and 2, and 10 patients (35.7 per cent) scored either 3 or 4. Eight (44.4 per cent) of the patients scoring between O and 2 received inappropriate antibiotics. All patients scoring 3 or 4 received antibiotics appropriately. Four (40 per cent), however, received the wrong antibiotics (co-amoxiclav (3), amoxycillin (1)). In 19 patients (67.8 per cent), advice was given about supportive therapy (paracetamol (eight), ibuprofen (four), paracetamol and ibuprofen (one), unspecified analgesia (four)).Two (7.1 per cent) patients required admission, for a possible diagnosis of quinsy.

TABLE II

STAGE THREE OF THE AUDIT

In stage three of the study, nine patients (29 per cent) scored a Centor Score between O and 2. Twenty-two patients (71 per cent) scored a Centor Score of 3 or 4. One patient (11 per cent) scoring between O and 2 received antibiotics inappropriately. All patients (100 per cent) with a Centor Score of 3 or 4 received antibiotics both appropriately and correctly. Eighteen patients (58 per cent) received advice about supportive treatment (paracetamol (nine), aspirin (three), ibuprofen (two), Difflam (two), co-codamol (one), paracetamol and saline gargle (one)). One patient (3 per cent) was referred to ENT as an outpatient and three (9.7 per cent) patients were admitted. No patients re-attended.

Introduction of a clinical scoring system reduced the inappropriate prescribing of antibiotics from 44 per cent in stage one to 11 per cent in stage three. Correct antibiotic prescription rose from 60 per cent to 100 per cent. Unfortunately, although the variety of advice given about supportive treatment increased, the actual number of patients receiving documented supportive advice fell from 67.8 per cent in stage one to 58 per cent in stage three.

Discussion

Affecting all ages and both sexes and although most patients do not seek medical advice,11 sore throat remains a common presentation to both GPs and EDs. Most patients present with a sore throat (usually lasting more than three days), anorexia, absence of cough, and lethargy, with or without systemic illness. Abnormal signs include inflamed tonsils, purulent tonsillar exudates, fever, and anterior cervical lymphadenopathy. UK figures suggest that consultation rates (per capita per annum) vary between 0.08 and 0.2.12 In the United States (US) an estimated 6.7 million adults with sore throats visit GPs13 and over a 10 year period, 70 per cent of adults were prescribed antibiotics.20 In Australia, sore throat is the second commonest reason for patients to seek medical advice,14 with 88.7 per cent of patients receiving antibiotic prescriptions.15 However, the prevalence of Group A-haemolytic streptococcus in adults with pharyngi\tis is only 5 to 15 per cent.2- 4

Diagnosis of Group A-haemolytic streptococcus

The best method of diagnosing Group A-haemolytic streptococcus remains controversial. In the US, guidelines recommend routine throat swabs and rapid antigen tests (RAT). In the UK, neither test is recommended routinely. Additionally, the results of commonly used tests are not available at the time of patient consultation and the decision, therefore, remains clinical. Many studies use throat swabs as the ‘gold standard’ for diagnosing Group Ahaemolytic streptococcus. Although probably the best indicator of treatment response, they do not distinguish between acute infection and carrier states.16,17 Furthermore, the results rely upon technique, sampling site,18 culture medium,19,20 incubation conditions,25,26 and whether the results are checked at 24 or 48 hours.25,26 Routine use, therefore, cannot be recommended but they may be useful for monitoring outbreaks of Group A-haemolytic streptococcus.

RATs have reported sensitivities of 65 to 91 per cent and specificities of 62 to 97 per cent depending upon the type of test and the clinical setting.21,27 These tests allow immediate treatment decisions, have a greater specificity for predicting Group A- haemolytic streptococcus than clinical models, but do not change antibiotic prescribing.22 RAT should not be carried out routinely in sore throat5 but may be indicated when patients are at moderate risk for Group A-haemolytic streptococcus infections, based on the clinical score, or if the treating physician is not comfortable with treating a high-risk patient empirically or with further testing in a low-risk patient.23

In the ED, clinical examination is relied upon to distinguish the possibility of Group A-haemolytic streptococcus from other causes of pharyngitis. Various clinical scoring systems exist3,4,24,28 but the most reliable predictor of Group A-haemolytic streptococcus is the Centor Score.13 Compared with a throat swab, the sensitivity and specificity of three or four clinical criteria for identifying patients with likely Group A-haemolytic streptococcus is 75 per cent and 75 per cent.13,28,31

Rationale behind antibiotic prescribing

Traditionally, clinicians prescribe antibiotics to relieve symptoms, to prevent disease transmission, and to prevent Group A- haemolytic streptococcus-associated complications – rheumatic fever, acute glomerulonephritis, and suppurative tonsillitis. Symptomatic relief concerns both patients and treating clinicians. Antibiotics started within two to three days of symptom onset shorten symptom duration by one to two days in patients with proven Group A- haemolytic streptococcus or in populations with a high prevalence of Group A-haemolytic streptococcus; this effect, however, is not seen in patients with negative cultures.23,24,25,28,31 No studies specifically examine antibiotic effect on other clinical indicators, such as return to work and other activities.

Group A-haemolytic streptococcus often occurs in epidemics, with spread increased in the presence of overcrowding and close contact. Antibiotics, therefore, are recommended to reduce spread within schools and closed institutions.24 As it is difficult to demonstrate that antibiotics reduce spread in the general population, they should not be prescribed for this purpose.

The association between pharyngitis and rheumatic fever was first reported in 1889 and rheumatic fever prevention remains a common reason for prescribing antibiotics in pharyngitis.25 Whilst rheumatic fever remains a major cause of mortality in developing countries, it is rare in developed countries.35 Early randomised trials, in populations with a high incidence of rheumatic fever, demonstrated that penicillin treatment for pharyngitis has a preventive effect against rheumatic fever.35 However, with the decline in disease incidence, the number needed to treat is now approaching 4000(33) and in the developed world antibiotic prescription should be rationalised.

Although the incidence of suppurative complications following acute pharyngitis is low,28,31,32 evidence suggests that antibiotics decrease the incidence of quinsy,33 particularly if antibiotic use is targeted at patients clinically at risk from Group A-haemolytic streptococcus.28,31 Conversely, two GE studies19,36 suggest that antibiotics do not reduce the incidence of quinsy because patients present after the complication has developed.

Which antibiotic?

Early evidence for the prevention of Group A-haemolytic streptococcus-associated complications came from trials involving the intramuscular administration of penicillin.35 There are no reasons, however, to suggest that other routes of administration are less effective. In the absence of evidence suggesting the development of antimicrobial resistance,35 penicillin remains the antibiotic of choice for patients with suspected Group A-haemolytic streptococcus. In penicillin-allergic patients, erythromycin should be prescribed.5

Other treatment

Symptomatic therapy plays an important management role in adult patients with pharyngitis and it can be divided into a number of categories:

(1) General measures – adequate fluid intake and salt water gargles11

(2) Simple analgesics/antipyretics – paracetamol, a safe and effective analgesic/antipyretic, is the drug of choice for analgesia in pharyngitis5

(3) Non-steroidal anti-inflammatory drugs (NSAIDs) – compared with placebo, aspirin, and paracetamol, ibuprofen has been shown to be a safe and effective analgesic agent. The studies5 are small and the possibility of gastrointestinal bleeding means that its routine use cannot be recommended

(4) Throat lozenges/gargles – may be helpful in patients with significant painx5,11

(5) Dexamethasone – has been used as adjuvant therapy in severe exudative pharyngitis and is effective in reducing pain. The study, however, only involved a small number of patients5,111

(6) Vaccination – vaccination against influenza and pneumococcus reduces the number of future episodes of pharyngitis but data is limited5

Conclusion

Sore throat is a common presentation to the ED. Traditionally, antibiotics are prescribed for patients with pharyngitis in an attempt to reduce symptoms and Group A-haemolytic streptococcus- associated complications. Although several guidelines exist to assist healthcare practitioners in their management of pharyngitis, they are inconsistent and many rely on serological or microbiological tests. In the ED, the results of these tests are not readily available, and diagnosis therefore relies on clinical judgment. Consequently, clinical scoring systems have been devised and in the ED setting the most useful is the Centor Score, a clinical scoring system originally designed to assist emergency physicians in their management of pharyngitis.

This audit cycle demonstrates that, without a scoring system (stage one) antibiotic prescription is inappropriate in a significant proportion of patients (44 per cent) and that following the implementation of a guideline advocating the use of a scoring system (stage three), inappropriate prescribing is considerably reduced (11 per cent). The percentage of patients receiving the correct antibiotics also increased (from 60 per cent to 100 per cent) when a proforma was used. Although the numbers in this audit are relatively small and the results may be altered by the Hawthorne effect, it suggests that a clinical scoring system should be used and that the audit should be repeated with larger numbers.

* This is a completed audit of the management of adults with sore throat in an inner city teaching hospital

* A retrospective study of the use of antibiotics was first performed and, after research as to the need for antibiotic therapy, a clinical scoring system was designed to inform future prescribing habits

* Over-prescribing and incorrect antibiotic prescribing was found to be common but, after introduction of a simple scoring system, was reduced. There was a parallel reduction in the supportive documentation that was distributed

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S L WOOLLEY, FFAEM, J M BERNSTEIN, MBCHB, J A DAVIDSON, FACEM, D R K SMITH, MRCS*

From the United Bristol Healthcare Trust, Bristol, UK, and the *University Hospital of Wales, Cardiff, UK.

Accepted for publication: 1 March 2005.

Address for correspondence:

Dr S Woolley

Emergency Department

United Bristol Healthcare Trust

Upper Maudlin Street

Bristol, UK.

E-mail: woolley_s@hotmail.com

Dr S Woolley takes responsibility for the integrity of the content of the paper.

Competing interests: None declared

APPENDIX ONE

Copyright Royal Society of Medicine Press Ltd. Jul 2005