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FeverPAIN. 8th of September, 2018 POST·MERIDIEM 11:18

At the beginning of 2018, Public Health England published a clinical decision rule for doctors managing sore throat, advising:

‘[Use] of the FeverPAIN or Centor clinical prediction score to determine the likelihood of streptococcal infection (and therefore the need for antibiotic treatment):’

In the context of a pending non-MICGP post-graduate exam I am obliged to remember this clinical rule and regurgitate it onto the page the day of the exam. I have no plans to use it in practice.

Here are its weaknesses as they occur to me:

  • The first line antibiotic for sore throat is phenoxymethylpenicillin. Don’t let the extra five syllables distract you; this is just penicillin. Penicillin. Penicillin has been in clinical use since 1942, and there is very very limited value to improved antibiotic stewardship for it; anything that was going to develop resistance to it, has developed resistance to it, more conservative deployment of it is very very unlikely to lower levels of MRSA, nor, on the other hand, is it likely to provoke resistance among T. pallidum.
  • The study the FeverPAIN score is based on, to its credit, uses several different swabs to pick up the Streptococcus that is the cause of most bacterial pharyngitis. Still, guess what? The sensitivity of every test we have available to pick up the specific pathogen of most infectious disease is terrible. 38% in a 2015 US study of community-acquired pneumonia significant enough to require hospitalisation, with the resources of the US federal government behind it. There is every reason to think a significant proportion of those with negative near-patient testing for Streptococcus actually had that bacterium.
  • The guidance is hedged so that, basically, if one is worried about the patient, one should go ahead and prescribe antibiotics. Well. Wasn’t that what we were doing anyway? Except, if the patient had immunocompromise I certainly was starting with co-amoxiclav rather than phenoxymethylpenicillin.
  • Personally, I come to this from an odd angle, in that I have the constitution of a horse, and so for years I listened to the guidance of, ultimately, the microbiologists, and just got on with things when I had a respiratory tract infection, without real problems. Then I got married, I got an RTI with cough productive of green sputum, struggled through, and then gave it to my wife, who was wiped out for a week or so. So, next time I got an RTI with cough productive of sputum, I took an antibiotic. Guess what? Even if the number of days one is symptomatic doesn’t change, it’s far far easier to work when antibiotics are doing their job against your bacterial infection.
  • And, of course, the people you’re not that worried about, and for whom you would consider withholding antibiotics, are the people healthy enough to have a job and to pay tax. And, well, having a job and working matters, those people have people depending on them for rent and clothes and home heating, and their taxes are where all the medical care for everyone else ultimately comes from.

In summary; if you’re a doctor reading this; if there is any whisper of a sore throat being bacterial, give the patient the penicillin. The patient will be happier and likely less sick, there will be little to no further resistance to penicillin in the community, and you won’t have to think about wasting time with penicillin if they re-present because of a resistant organism.

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