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Primary Care

Penicillin for acute sore throat in children: randomised, double blind trial

BMJ 2003; 327 doi: (Published 04 December 2003) Cite this as: BMJ 2003;327:1324

Penicillin for acute sore throat in children?

Dear Editor

We read with interest the report of the randomised controlled trial
of penicillin for sore throat in children by Zwart and colleagues.[1] This
is an important study as little data exist to guide the treatment of
children and it demonstrated the lack of effect on outcomes important to
patients and parents, namely symptom duration, school attendance and
recurrence of infections. However, with regard to streptococcal sequelae,
the authors found an inverse relationship between children with sequelae
(14%, 4% and 2%) and increasing duration of penicillin (0, 3 and 7 days
respectively). The probability of this finding occurring by chance is 0.03
(chi-square test).

We wish to raise three issues regarding this finding. The first is
that ‘imminent quinsy’ accounted for 82% of sequelae. However, the authors
do not clearly define what they meant by this term and so the implications
for clinical practice remain uncertain. Second, although the authors’
conclude that they had insufficient power to draw firm conclusions, and we
acknowledge their restraint in not overstating a secondary result, we feel
this is an important finding that deserves replication. Furthermore, if we
are to rationalise the use of antibiotics in primary care, it would be
useful to know if there are any clinical factors, for example fever[2,3]
or vomiting,[3] associated with the development of such sequelae. Finally,
what should the message be to parents and children? If presented with
these data, including the lack of increased side effects associated with
penicillin, we think many would opt for a three or seven day course of
antibiotics to prevent the pain, discomfort and inconvenience of ‘imminent
quinsy’. Given that the decision to prescribe antibiotics in primary care
is often finely balanced and frequently influenced by patient
expectations,[4] trials of antibiotics need to include the full complement
of outcomes important to prescribing. These are symptomatic outcomes, side
effects, complications and, importantly, antibiotic resistance.[5] Only
then will clinicians and patients be able to engage in fully informed and
balanced decision-making.

Reference List

1.Zwart S, Rovers MM, de Melker RA, Hoes AW. Penicillin for acute
sore throat in children: randomised, double blind trial. BMJ 2003;327:1324

2.Hay AD, Fahey T, Peters TJ, Wilson AD. Predicting complications
from acute cough in pre-school children in primary care: a prospective
cohort study. Br J Gen Pract 2004;(in press).

3.Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I et
al. Predictors of poor outcome and benefits from antibiotics in children
with acute otitis media: pragmatic randomised trial. BMJ 2002;325:22.

4.Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of
patients' expectations on antibiotic management of acute lower respiratory
tract illness in general practice: questionnaire study. BMJ 1997;315:1211-

5.Schrag SJ, Pena C, Fernandez J, Sanchez J, Gomez V, Perez E et al.
Effect of short-course, high-dose amoxicillin therapy on resistant
pneumococcal carriage: a randomized trial. JAMA 2001;286:49-56.

Competing interests:
None declared

Competing interests: No competing interests

19 December 2003
Alastair D Hay
Clinical Lecturer in Primary Health Care
Alan A Montgomery, Lecturer in Primary Care Research
Division of Primary Health Care, University of Bristol, Cotham House, Cotham Hill, Bristol BS6 6JL