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Most Antibiotics Prescribed For Sore Throat Unneeded - Fox News

Most Americans with a sore throat are prescribed antibiotics even though just a fraction stand to benefit from them, a new study shows.

Researchers said only about 10 percent of adults with sore throats have strep throat, which is caused by bacteria that could be killed by antibiotics.

Almost all other sore throats are caused by viruses. In those cases, "an antibiotic is not going to help you and it has a very real chance of hurting you," Dr. Jeffrey Linder, who worked on the study at Brigham and Women's Hospital in Boston, said.

Although serious side effects are rare, he said antibiotics can cause diarrhea or yeast infections and interact with other medicines. Overuse of the drugs also makes bacteria resistant to them - which means future infections could be harder to treat.

For their study, Linder and his colleague Dr. Michael Barnett analyzed data on 8,200 U.S. Primary care and emergency room visits for sore throats between 1997 and 2010.

They found doctors prescribed an antibiotic at 60 percent of those visits, with no change in that rate during the study period, according to findings published in JAMA Internal Medicine.

What did change is that a greater proportion of prescriptions were for new, expensive antibiotics in recent years - even though penicillin works just fine against strep throat, Linder told Reuters Health.

His team's findings were presented Thursday at IDWeek 2013 in San Francisco.

The researchers noted that they didn't have data on each patient's diagnosis, so they couldn't know exactly when antibiotics were appropriate.

Linder said ideally, doctors should use a few key symptoms to figure out which patients should be tested for strep throat. Patients are more likely to have strep if they have a fever, swollen lymph nodes, white spots on the tonsils or swollen tonsils and no cough.

But the test is often used "pretty indiscriminately," or people are given antibiotics without even being tested for strep, Linder said.

Dr. Ralph Gonzales, who has studied antibiotic prescribing at the University of California, San Francisco, said the results weren't all bad news, necessarily.

The proportion of people visiting their primary care doctor for a sore throat - rather than any other complaint - dropped from almost 8 percent to about 4 percent during the study period, he noted.

He said fewer total visits for sore throats means fewer antibiotics are being prescribed - even if most people with achy throats still get the drugs.

"At least from a public health perspective, we're having a lower impact on resistance," Gonzales, who wasn't involved in the new research, told Reuters Health.

Dr. Paul Little, a professor of primary care research at the University of Southampton in the UK, said people can avoid getting unneeded antibiotics by not going to the doctor for a run-of-the-mill sore throat.

"The truth is, nasty things are really pretty uncommon," Little, who also didn't participate in the study, told Reuters Health. "What you need to do is manage your symptoms," he said, such as with over-the-counter pain relievers and plenty of fluids.

"The vast, vast majority of these are going to get better on their own," Linder agreed.

Still, Little said, "If you're worried about it and you're very unwell … then I think it is worth it to see a doctor and have a (strep) test."

My Throat Hurts: A Clinical Approach To Strep Throat Diagnosis And Treatment

Up to 6% of pediatric visits are because of complaints of sore throat.1 Strep throat is a bacterial infection in the oropharynx that commonly results from Group A Streptococcus (GAS), also known as Streptococcus pyogenes.2 GAS pharyngitis is most common in children between 5 and 15 years of age, with the highest annual occurrence from winter through early spring.3

The typical presentation of GAS pharyngitis is a child with a sore throat, pain associated with swallowing, abrupt fever of 100.4°F (38°C) or greater, malaise, headache, and mild neck stiffness.4 On inspection, the throat may show erythema, pharyngeal and uvulal edema, lymphoid swelling posterior to the pharynx, and tonsillar pillars that are gray-white or exudative.5  Gastrointestinal symptoms are more common in younger children, who may complain of nausea, vomiting, and abdominal pain.3 Younger patients more commonly present with nonspecific symptoms with a more gradual onset.3 Bacterial throat and viral upper respiratory tract infections can have overlapping symptoms of fever, headache, malaise, and sore throat.4 Antibiotics will help a bacterial GAS infection, but not viral rhinitis.6

Tonsillar Swelling/Assessment

During the head, eyes, ears, nose, and throat (HEENT) exam, staging tonsillar swelling from zero to 4 helps diagnose and rule out life-threatening conditions.7 It is not uncommon for tonsils to remain swollen throughout childhood.7 A careful history review should evaluate for symptoms of sleep apnea, snoring, and recurrent infections.7 In the absence of infection and obstructive breathing, the tonsils can be left in place with regular monitoring.7

Literature Review

A review of the literature on the current GAS pharyngitis diagnostic and treatment recommendations resulted in 9 relevant articles (Table 1).6,8-15 Treatment recommendations center on safe and effective medications that preserve antibiotic viability. Most of the synthesized recommendations in this article combine the recommendations from the literature, the Centers for Disease Control and Prevention (CDC), and UpToDate.

Diagnosis

The first and best diagnostic tools clinicians can use are a thorough history, a careful examination, and a systematic approach to assessment. It is wise to divide all possible differentials by categories (viral, bacterial, fungal, endocrine, other causes) so that the diagnosis can be systematic and logical. The most common cause of pharyngitis is viral, followed by GAS.16 Although 15% to 30% of throat cultures will be positive for GAS, cultures do not distinguish between symptomatic and asymptomatic carriers of GAS.16 Diagnosis and treatment of GAS pharyngitis is subjective, leading many providers to rely on intuitive decision-making, regardless of diagnostic results.8,9

Differentiating Between Viral and Bacterial Causes

Up to 80% of sore throats have a viral etiology.1 Testing for GAS pharyngitis can be troublesome because typical tests do not distinguish between invasive deep tonsillar infections and asymptomatic surface colonization.16 Up to 12% of asymptomatic patients are positive for GAS when tested.1,16 Nevertheless, up to 60% of all pharyngitis presentations are treated with antibiotics, increasing the risk for antibiotic misuse, cost, and unnecessary side effects.17 Distinguishing features in viral rhinitis include sneezing, watery eyes, and nasal congestion.18 GAS pharyngitis, on the other hand, presents with painful swallowing and is often associated with inflamed tonsils in the absence of other respiratory symptoms.2

Testing

The Infectious Disease Society of America endorses rapid antigen diagnostic tests (RADTs) followed by confirmatory bacterial culture for negative RADTs in the diagnosis of GAS pharyngitis.10 RADTs are advantageous for cost and results within 15 minutes compared with traditional cultures, which can take up to 48 hours to complete.10 Because of the combined accuracy of throat cultures paired with RADT and the reduced sensitivity of RADT alone, throat cultures should be collected simultaneously to confirm negative RADT.13 Providers may consider newer and alternative testing with polymerase chain reaction, nucleic acid amplification, multiple cross displacement amplification, bloodwork, and photographic analysis.6,11-14 Blood work that includes inflammatory markers may be necessary when distinguishing symptomatic from asymptomatic carriers.

Centor Criteria

The Centor criteria are used to help providers determine if a patient might require further GAS pharyngitis diagnostics and treatment (Table 2).4 According to a Centor criteria analysis performed in the United Kingdom, patients with a Centor score of 4, 3, 2, and 1 point have positive predictive values for GAS pharyngitis diagnosis of 25%, 25.7%, 23.7%, and 17.2%, respectively.19 On the flip side, patients with a combined Centor score of 4, 3, 2, and 1 point have negative predictive values for absent GAS pharyngitis diagnosis of 83.1%, 85.5%, 89.3%, and 89.7%, respectively.19

Treatment and Follow-Up Recommended Antibiotics

There are several recommended treatments for GAS pharyngitis (Table 3).20,21 First-line therapy for GAS is penicillin.20Amoxicillin, a broad-acting penicillin, is often preferable because of its more tolerable taste, availability, and once-daily dosing.15 Benzathine penicillin G, given in a single intramuscular injection, is also recommended for patients with resistant strep or at increased risk for medication noncompliance.20 For patients with non-IgE–mediated penicillin allergies, the CDC recommends first-generation oral cephalexin or cefadroxil.20 For those with IgE-mediated penicillin allergy, the CDC recommends clindamycin or azithromycin and clarithromycin.20 Adding flavor enhancers to any of these recommended treatments is an inexpensive way to help overcome the challenges of unpleasant-tasting medications.22

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Up to 80% of sore throats have a viral etiology … Nevertheless, up to 60% of all pharyngitis presentations are treated with antibiotics, increasing the risk for antibiotic misuse, cost, and unnecessary side effects.

Addressing Symptoms

Symptomatic treatment recommendations include soothing foods, hydration, and avoidance of environmental triggers. Ice pops can be a great way to provide cold comfort to sore throats while improving hydration. Patients who feel well enough to return to school may do so 24 hours after antibiotic initiation if they are fever-free without the aid of fever-reducing medicine.23 Parents should monitor children for hydration, new joint pain within 1 month of having strep throat, and persistent symptoms after the completion of antibiotics.24

Alternative Antibiotics

The FDA has approved 5-day treatment courses for GAS pharyngitis with broad-acting cefdinir, cefpodoxime, and azithromycin.15 Careful revaluation of GAS pharyngitis eradication should be considered after these short-course treatments because they have been shown to be effective at short-term treatment but not long-term eradication of GAS.20 Broad-spectrum antibiotics should be used with caution because their overuse may lead to antibiotic resistance.20 The World Health Organization considers macrolide and cephalosporin antibiotics critical resources for world health that should be used judiciously to prevent antibiotic resistance.15

Treating Penicillin Allergies

Patients with non-IgE–mediated reactions to penicillin may tolerate cephalosporins.21Those with true IgE-mediated hypersensitivity allergies to penicillin will require a non-cephalosporin treatment, such as a macrolide or lincosamide antibiotic.21 A history of requiring antihistamines or epinephrine to control a penicillin reaction supports the diagnosis of an IgE-mediated allergy. The use of penicillin alternatives should be considered carefully in the light of antibiotic stewardship and best practice considerations for treating GAS.

Strep Throat Is Surging, Alongside An Antibiotic Shortage

Covid-related precautions helped minimize the spread plenty of other communicable diseases. But now, those bugs are back, along with some new challenges. The CDC reports that strep A infections (a.K.A strep throat), caused by a bacterium known as A Streptococcus, have surged from covid lows to above pre-pandemic levels in 2022 and 2023. And the recent spike in strep cases coincides with a shortage of one of the medicines most commonly used to treat the infections, particularly in children, as pointed out in a Monday NPR report.

Nationwide, the biggest sustained increase in the number of the most severe strep cases (known as invasive group A strep infections) has been observed in children, according to the CDC. And kids are the group most affected by ongoing antibiotic scarcity.

Currently, many dosages of liquid amoxicillin, the goopy bright pink drug of choice for pediatric strep infections, are in short supply, according to the Food and Drug Administration. And it's been this way for months. Many forms and brands of the powders used in liquid amoxicillin formulas have been under an official FDA shortage since October 2022. Most of the pharma companies that manufacture the stuff have listed "demand increase for the drug," as the reason behind its limited availability.

Though higher than the past normal, strep infection levels haven't appeared to reach any sort of record levels in recent months. However, as NPR notes, companies often rely on recent sales data to inform their production. In using pandemic years as data points, these pharmaceutical manufacturers many have miscalculated.

"Companies typically look to see what their sales were the prior year. They might make a little bit of an adjustment," Erin Fox, a medication use and policy researcher at the University of Utah, told NPR. "With the really severe respiratory season we've had this year, it just simply was a mismatch between what people manufactured and what was available," she added.

There are alternative options for treating strep infections. Doctors can prescribe other dosages or pills over certain liquid forms of amoxicillin. However, getting kids to swallow pills or larger volumes of liquid medicine can be a challenge.

Doctors may prescribe a medicine unaware it's in short-supply, putting the onus on the patient or patient's family to navigate the pharmacy system and find what they were told they need. Caitlin Rivers, a Johns Hopkins University epidemiologist, told NPR she had to go to multiple pharmacies in order to find a prescribed antibiotic for her own child. "It just adds another burden on what's already been a really difficult winter respiratory season for families," she said to the outlet.

But despite the inconvenience, getting proper medication for strep is critically important. Untreated, strep A infections can lead to serious, long-term consequences like organ damage or rheumatic fever.

The worst time of year for strep infections is often December through April, so the spike in cases and concurrent struggle to find meds could settle down soon. But years of pandemic threw many seasonal infection cycles out of whack, and there's no guarantee that next month will bring relief, Rivers said.

Over the past year, the FDA has declared shortages on many commonly prescribed medications, including other antibiotics. Other shortages include certain types of ADHD medications like immediate release Adderall and multiple brands of a newer class of diabetes drugs that are also often used for weight loss. Supply chain disruptions, increases in demand, and a mix of other factors are to blame.

Regardless of the causes, drug shortages can have significant negative impacts on medical care, quality of life, and health. Out of desperation, some people have sought out unsafe sources of medication, like pharmacies outside of the U.S., which may not be selling things exactly as labeled.

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