As one who has followed the debate about management of sore throats for some time and attempted to bring some reason to the emergency practice of this condition,1–3 I was not surprised to see the seemingly divergent opinions of Drs. David Peterson, James Roberts, Jerome Hoffman, and Richard Bukata. Dr. Peterson asked for evidence-based medicine. I was surprised that the respondents did not cite the 1999 Cochrane review on this topic.4 Although the senior author of the Cochrane review has long had a nontreatment bias regarding sore throats, the literature on this topic is nicely summarized in the review and the reasons for controversy made clear.
Based upon clinical trial data, the Cochrane review notes that there is strong evidence that antibiotics can reduce the risk of rheumatic fever and suppurative complications (i.e., otitis media, sinusitis, peritonsillar abscess). Furthermore, about 20 percent more patients were asymptomatic with antibiotic treatment three days after initial evaluation. Similar findings were noted for specific symptoms of throat pain, headache, and fever. There also was a trend for protection against acute glomerulonephritis with antibiotic treatment, but the “numbers of cases were too low to be sure of this effect.”
Despite these favorable effects, the review authors do not strongly endorse routine antibiotic use. Rather, they note that the risk of rheumatic fever is nominal in most parts of the world, the risk of suppurative complications are low with routine sore throats, the reduction in symptom duration appears to be small (0.5 to 1.0 days, by some estimates), and the risks of antibiotics are real. Given this information, it is clear why experienced clinicians take different perspectives.
Antibiotics do work for many patients with sore throats. Regimens which provide early antibiotic therapy for the most symptomatic (or at risk) patients seem to represent the common ground. That is, empiric treatment of those patients for whom the treatment will provide the most benefit is the common theme. The rub is how we define that high-risk group. Hopefully, future, large multicenter studies will help us define the benefit of selective early empiric therapy.
Jerris R. Hedges, MD
1. Hedges JR, Singal BM, Estep JL. The impact of rapid screen for streptococcal pharyngitis upon clinical decision making in the emergency department. Med Dec Making
2. Hedges JR, Lowe RA. Streptococcal pharyngitis in the emergency department: Analysis of therapeutic strategies. Am J Emerg Med
3. Lowe RA, Hedges JR. Early treatment of streptococcal pharyngitis. Ann Emerg Med
4. Del Mar CB, Glasziou PP. Antibiotics for sore throat. The Cochrane Database of Systematic Reviews
Vol 3. 1999 pp. 1–28.