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EDITORIALS: Chris Del Mar Sore throats and antibiotics BMJ 2000; 320: 130-131 [Full text]

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Changing doubts

Mark Holloway   (17 January 2000)

single dose prophylaxis at outset

S Ravi   (18 January 2000)

Evidence based - sore throats and antibiotics

Tim Owen   (4 February 2000)

Changing doubts 17 January 2000
Mark Holloway, Company Medical Officer , Brunei Shell Panaga Hospital Brunei Send response to journal: Re: Changing doubts	As an inexperienced untrained rural doctor I used to prescribe Amoxil for sore throat. I usually swabbed the throat. As an experienced untrained rural doctor I started prescribing penicillen V for 10 days and often swabbed. As a clinical fellow in academic practice I treated only those with high fever, tender swollen glands, severe inflammation or scarletina rash, and never swabbed! As an experienced trained rural pratitiioner I no longer swabbed but made a probability estimate, based on a cluster of symptoms and signs. In the end, I often said "I don't think you really need this antibiotic. Wait another 48 hours, keep this script in your pocket.Take it if you are not better." It was usually thrown away! In the last few years I rarely prescribed unless I had a strong intuition of "strep throat". Articles appeared that seemed to justify this with evidence of low complication rates and the decline of rheumatic fever. Shortly after, I stopped giving one young patient penicillen for a very dubious 'sore throat'. She had been on it for 5 days had very little signs or symptoms. The next day she went to another hospital with the first classic signs of Rheumatic fever. I doubted the diagnosis, justified myself in saying "penicillen didn't stop it". It was a genuine rheumatic fever, fortunately no sequelae, but she is my regular patient and on prophylaxis. I had another case of post strep chorea in another patient. I completely missed the diagnosis of rheumatic fever 18 months before but it was all so obvious in hindsight. I even did the ASOT. He did not present until he had the rheumatic fever! I don't let individual experiences sway me. I still rarely prescribe penicillen unless my intuition or my patient tells me, but I do prescribe it for at least 7 days. I don't think anyone takes it for 10!
single dose prophylaxis at outset 18 January 2000
S Ravi, consultant surgeon Blackpool Victoria Hospital Send response to journal: Re: single dose prophylaxis at outset	I wonder if single dose prophylaxis is worth a look. In surgery single dose prophylaxis is the norm. In fact when antibiotics are prescribed prophylactically for more than 1 or 3 doses, the infection rate goes up. In Condon's study, when the first dose was given at the time of induction of anaesthesia for surgery, the rate of wound infection was 4%. When antibiotic was given for a week the infection rate was 6.9%. Repeating the study did not change the rather surprising result. Why not then consider a single mega dose at the outset of sore throat? I keep a stock of ciprofloxacin and do believe that a single dose of 1gm aborts the infection or decreases the duration of the disease. It is worth a trial. The microbiologist at my hospital disagrees with me; I think it can even prevent meningitis taking root if the initial dose is a mega dose of a penicillin!
Evidence based - sore throats and antibiotics 4 February 2000
Tim Owen, General Practitioner Ethel Street Surgery, Benwell, Newcastle upon Tyne, NE4 8QA Send response to journal: Re: Evidence based - sore throats and antibiotics	Editor – Del Mar’s editorial on sore throats and antibiotics¹ is a useful contribution to the subject but perhaps more useful is the common sense that it brings to the wider field of evidence based medicine. It is good to see evidence based medicine being described as a step in the process of clinical management rather than a final solution to all management problems. It is important to realise that evidence based information must be sought on all aspects of the clinical problem. Information on the benefits of therapeutic intervention are incomplete without information on dis-benefits (such as side effects etc.). While the complex problem of the various pieces of the information jigsaw must be wrestled with by those responsible for service development and resource expenditure, (which is increasingly all clinicians), the editorial, correctly, identifies that for clinicians in face to face consultation, the ideal is to share the evidence with patients and allow them a genuine input to the resultant decision. Dr Tim Owen, General Practitioner