Antibiotic prescription for sore throat or the legacy of Mr X2

Abstract

In his 1945 Nobel lecture, Sir Alexander Fleming described a hypothetical “Mr. X, [who] has a sore throat…buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin”. 1 Fleming A Penicillin. Nobel lecture. http://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.pdfDate: Dec 11, 1945 Google Scholar Ironically, this eminent scientist selected group A streptococci for his example—the leading cause of bacterial pharyngitis and almost the sole organism that remains universally susceptible to penicillin in an era of multidrug-resistant bacteria. 2 Horn DL Zabriskie JB Austrian R et al. Why have group A streptococci remained susceptible to penicillin? Report on a symposium. Clin Infect Dis. 1998; 26: 1341-1345 Crossref PubMed Scopus (99) Google Scholar However, more generally, Fleming was prescient; antibiotic misuse drives antimicrobial resistance and pharyngitis—mainly caused by respiratory viruses—is a cornerstone of antibiotic overuse in the community. Findings of a recent analysis 3 Barnett ML Linder JA Antibiotic prescribing to adults with sore throat in the United States, 1997–2010. JAMA Intern Med. 2013; (published online Oct 3.)https://doi.org/10.1001/jamainternmed.2013.11673 Crossref PubMed Scopus (109) Google Scholar of US outpatient data between 1997 and 2010 showed that antibiotics—often macrolides instead of penicillins—were prescribed to 60% of patients who visited the clinic or emergency department because of sore throat. Although most guidelines concur that penicillins should be first-line in the antibiotic treatment, marked heterogeneity exists as to when that treatment should be deployed to prevent complications. 4 Chiappini E Regoli M Bonsignori F et al. Analysis of different recommendations from international guidelines for the management of acute pharyngitis in adults and children. Clin Ther. 2011; 33: 48-58 Summary Full Text Full Text PDF PubMed Scopus (110) Google Scholar , 5 Shulman ST Bisno AL Clegg HW et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012; 55: 86-102 Crossref Scopus (432) Google Scholar , 6 Pelucchi C Grigoryan L Galeone C et al. Guideline for the management of acute sore throat. Clin Microbiol Infect. 2012; 18: 1-28 Crossref PubMed Scopus (181) Google Scholar For a complaint as common as sore throat, the scarcity of observational data for the occurrence of complications in patients treated with or without antibiotics is therefore surprising. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort studySuppurative complications are not common in primary care and most are not serious. The risks of suppurative complications or reconsultation in adults are reduced by antibiotics, but not as much as the trial evidence suggests. In most cases, no antibiotic is needed, but a delayed prescription strategy is likely to provide similar benefits to an immediate antibiotic prescription. Full-Text PDF