Sore throats and antibiotics
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7228.130 (Published 15 January 2000) Cite this as: BMJ 2000;320:130All rapid responses
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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!
Competing interests: No competing interests
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!
Competing interests: No competing interests
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
Competing interests: No competing interests