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
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
- 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
- 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.