Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Penicillin and sore-throat - our dilemma.
- Friedrich Flachsbart (22 January 2003)
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Treatment of sore throats in developing countries
- G.N. Malavige (22 January 2003)
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Smell of a sore throat
- Matthew N. S. Hunt (23 January 2003)
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Sore throats, why the dilemma?
- Larry Martel (26 January 2003)
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Re: Sore throats, why the dilemma?
- stephen r. kettle (28 January 2003)
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Sore throats, antibiotics and the doctor-patient relationship
- Patrick GM Bolton, Michael Mira (21 February 2003)
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From Sore Throat to Severe Acute Respiratory Syndrome (SARS)
- Friedrich Flachsbart (18 March 2003)
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Friedrich Flachsbart, General medicine 37085 Göttingen
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Dear Sir, Streptococci are masking, they hide, they are intracellular. But streptococci still induce post-streptococcal-reactive diseases. 3 % of untreated strep-throat are followed by rheumatic sequelae. This number is still the truth. You have to take a world-wide perspective to understand. You have to go to Australia, like S. M. Wearne. She learned in the Outback: "..practising evidence-based medicine requires that sore throats are treated with penicillin, not just analgesics." The same is true in cold Goettingen. People suffer behind false concepts. Penicillin is able to eradicate the hidden pathogen. Sincerely Yours
Lit.: S. M. Wearne: Reflections on a year in the outback MJA 2002;177:117-118 Competing interests: None declared |
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G.N. Malavige, lecturer in Micobiology University of Sri Jayawardanapure, Sri Lanka
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Acute Pharyngitis is a leading cause of morbidity in the Paediatric age group. Although, viruses cause most of them it is not possible to differentiate this clinically. A throat swab and culture, which is the gold standard of diagnosis, is not available in most areas in Sri Lanka. Mitral valve prolapse and other valvular heart lesions as a result of rheumatic fever is still common in Sri Lanka. Therefore, in economically deprived countries like Sri Lanka it may be rational to prescribe antibiotics to all sore throats with view of preventing more serious complications. However, guidelines should be formed as to which antibiotics to prescribe in such situations. Some general practitioners prescribe very expensive antibiotics, mostly to impress the patients who believe that expensive antibiotics are more effective. Therefore, it is vital to educate the general public that sore throats can be treated effectively with cheap antibiotics such as oral penicillin. Competing interests: None declared |
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Matthew N. S. Hunt, GP Willingham Surgery, 52 Long Lane, Willingham, Cambridge, CB4 5LB
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Do any GPs use their sense of smell when deciding on an antibiotic prescription? I find that some sore throats smell of decaying flesh, reminding me of bacteriology practicals, whereas others look red and are exudative but don't smell. It seems to me from experience that this smell is associated with streptococcal infections. I have no statistically significant swab results to confirm this, but if I am weighing up whether to prescribe, a foul smell will make me decide to give an antibiotic. The smell isn't just halitosis since it is the same from patient to patient. Any microbiologists' views on this? Competing interests: None declared |
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Larry Martel, Consultant Paediatrician Warren Childrens Centre, Lisburn, BT28 1LQ
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I find is hard to believe that this argument still goes on about the treatment of sore throats, if I had the energy I would dig up the articles to support the following statements. 1. The only likely treatable organism in the throat is streptococcus, virtually all else is viral. 2. During the 2nd world war the US government decided that the only sensible treatment was to give all troups complaining of a sore throat an injection of penicillin. They were unlikely to complete a ten day course of antibiotics orally and the risk of anaphylaxis was less than the risk of a war injury. 3. Multiple studies show that it is very difficult to get anyone to comple a 10 day course of pennicillin. 4. Drug resistance is on the rise due to over use of antibiotics. 5. Rapid Strep tests have been available for over 10 years. They can give very reliable results within minutes. This have been standard practice in the United States for ages but is very unpopular with UK authorities. Could it be because the penicillin is cheaper than the test? 6. There is only weak evidence that treating strep throat with antibiotics hastens resolution of symptoms but we would like to believe that it will reduce the presence of secondary complications like Rheumatic fever and quicy (but not glomerulonephritis). If you are determined to reduce the over use of antibiotics either do a culture and wait 24 to 48 hours to treat positive results or do a rapid strep test and treate positives. Either stratergy will prevent complications and would be equally efficacious in relieving symptoms. In the third world or inner city where only relatively ill patients come to the doctor and compliance is difficult an injection of Pennicillin or short course of Zithromax is sensible. Once the patients realise that the complaint of sorethroat is greated with an injection they will be very judicious of their use of the doctor's services. Competing interests: None declared |
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stephen r. kettle, solo gp qld 4551 oz
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hear hear to dr martelin for the 1st world although i'm old-fashioned enough to use the colour of the supposed purulence of the sputum as my 'acid test' to pseudo-differentiate between viral & bacterial infections whilst there may be very little ebm for this it's the simplest for me & has the advantage that those pts. [ their parents ] who don't want to use an antibiotic have a
pseudo-respectable way out of so doing.
i also use unfashionable antibiotics such as septrin & doxycycline to treat purulent rti's which minimises the development of resistance to serious hospital frontline use antibiotics. i have had pts telling me about the prescriptions of quinolones or gentamycin for rti's which to me is mild overkill for these relatively benign conditions at least initially. however on the otherhand i have, when younger, followed the then current academic guidelines & not prescribed antibiotics for sore ears in young kids with subsequent perforation at least twice under my monitoring which endeared me neither to the pt & / or their mother / father. also what do you do with the pt. with a high pain threshold where i've had a few perforated ear drums as the 1st presentation as no / little pain was appreciated prior to the perforation. so the art of clinical medicine is far from dead esp, in the less-developed world [ sir humphrey speak for the old fashioned 3rd world ]. Competing interests: solo gp |
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Patrick GM Bolton, Conjoint Associate Professor, University of NSW Wollongong Hospital, Crown St Wollongong, NSW 2500, Australia, Michael Mira
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We are able to provide data to support the assessment by GPs that they do not need to prescribe antibiotics for sore throat in order to maintain their relationship with patients reported by Kumar and colleagues. We have collected data about diagnosis, treatment and patient satisfaction from 10,449 encounters in community general practice and a general practice staffed casualty service. Of these, 484 (4.6%) were by patients with a URTI, 306 (63.2%) of whom had been prescribed an antibiotic at that encounter. Patient satisfaction data were collected using the CSQ8b, an internationally validated patient satisfaction questionnaire (1). This instrument rates patient satisfaction on a four point scale on eight items, producing a maximum possible score of 32. Linear models were used to analyse the resultant data, controlling for patient age and sex and clustering at the level of the treating GP. The satisfaction on this scale of patients with URTI was heavily positively skewed, so on statistical advice we dichotomised patient satisfaction about the median and used logistic regression to compare the satisfaction of patients who received an antibiotic. This analysis controlled for patient age and sex, and clustering at the level of the treating GP. There was no difference between the satisfaction scores of patients with URTI who received an antibiotic and those who did not (p=0.722, OR 1.11, 95% CI 0.63-1.96). The median satisfaction of both patients who received and who did not receive an antibiotic was 31. In our study, it is not clear whether no difference in satisfaction was detected because receipt of an antibiotic has no impact on patient satisfaction, or whether GPs were able to successfully determine those factors which would maximise the satisfaction of their patients, and provide an antibiotic when patients desired this. Either way prescribing decisions need not, and appear not to, change patients’ satisfaction with the doctor-patient relationship. 1. Attkisson CC, Clifford C, Greenfield TK. Client Satisfaction Questionnaire-8 and Service Satisfaction Scale-30. Lawrence Erlbaum Associates, Inc, Hillsdale, NJ, US; xv, 637 pp 1995. Competing interests: None declared |
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Friedrich Flachsbart, General medicine 37085 Göttingen
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Dear Sir, the way from "mild sore throat" to systemic inflammatory response syndrome is sometimes very short. Streptococcus pyogenes does interact with coagulation, sometimes in a catastrophic manner. Yours H. Herwald, M. Mörgelin, B. Dahlbäck, L. Björck: Interactions between surface proteins of Streptococcus pyogenes and coagulation factors modulate clotting of human plasma. Journal of Thrombosis and Haemostasis 2003;1:284-291 Competing interests: None declared |
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