Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7381.138 (Published 18 January 2003) Cite this as: BMJ 2003;326:138
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We are able to provide data to support the assessment by GPs that
they do not need to prescribe antibiotics for sore throat in order to
maintain their relationship with patients reported by Kumar and
colleagues.
We have collected data about diagnosis, treatment and patient
satisfaction from 10,449 encounters in community general practice and a
general practice staffed casualty service. Of these, 484 (4.6%) were by
patients with a URTI, 306 (63.2%) of whom had been prescribed an
antibiotic at that encounter.
Patient satisfaction data were collected using the CSQ8b, an
internationally validated patient satisfaction questionnaire (1). This
instrument rates patient satisfaction on a four point scale on eight
items, producing a maximum possible score of 32.
Linear models were used to analyse the resultant data, controlling
for patient age and sex and clustering at the level of the treating GP.
The satisfaction on this scale of patients with URTI was heavily
positively skewed, so on statistical advice we dichotomised patient
satisfaction about the median and used logistic regression to compare the
satisfaction of patients who received an antibiotic. This analysis
controlled for patient age and sex, and clustering at the level of the
treating GP.
There was no difference between the satisfaction scores of patients
with URTI who received an antibiotic and those who did not (p=0.722, OR
1.11, 95% CI 0.63-1.96). The median satisfaction of both patients who
received and who did not receive an antibiotic was 31.
In our study, it is not clear whether no difference in satisfaction
was detected because receipt of an antibiotic has no impact on patient
satisfaction, or whether GPs were able to successfully determine those
factors which would maximise the satisfaction of their patients, and
provide an antibiotic when patients desired this. Either way prescribing
decisions need not, and appear not to, change patients’ satisfaction with
the doctor-patient relationship.
1. Attkisson CC, Clifford C, Greenfield TK. Client Satisfaction
Questionnaire-8 and Service Satisfaction Scale-30. Lawrence Erlbaum
Associates, Inc, Hillsdale, NJ, US; xv, 637 pp 1995.
Competing interests:
None declared
Competing interests: No competing interests
hear hear to dr martelin for the 1st world although i'm old-fashioned enough to use the colour of the supposed purulence of the sputum as my 'acid test' to pseudo-differentiate between viral & bacterial infections whilst there may be very little ebm for this it's the simplest for me & has the advantage that those pts. [ their parents ] who don't want to use an antibiotic have a
pseudo-respectable way out of so doing.
i also use unfashionable antibiotics such as septrin & doxycycline to treat purulent rti's which minimises the development of resistance to serious hospital frontline use antibiotics.
i have had pts telling me about the prescriptions of quinolones or gentamycin for rti's which to me is mild overkill for these relatively benign conditions at least initially.
however on the otherhand i have, when younger, followed the then current academic guidelines & not prescribed antibiotics for sore ears in young kids with subsequent perforation at least twice under my monitoring which endeared me neither to the pt & / or their mother / father.
also what do you do with the pt. with a high pain threshold where i've had a few perforated ear drums as the 1st presentation as no / little pain was appreciated prior to the perforation.
so the art of clinical medicine is far from dead esp, in the less-developed world [ sir humphrey speak for the old fashioned 3rd world ].
Competing interests:
solo gp
Competing interests: No competing interests
I find is hard to believe that this argument still goes on about the
treatment of sore throats, if I had the energy I would dig up the articles
to support the following statements.
1. The only likely treatable organism in the throat is streptococcus,
virtually all else is viral.
2. During the 2nd world war the US government decided that the only
sensible treatment was to give all troups complaining of a sore throat an
injection of penicillin. They were unlikely to complete a ten day course
of antibiotics orally and the risk of anaphylaxis was less than the risk
of a war injury.
3. Multiple studies show that it is very difficult to get anyone to
comple a 10 day course of pennicillin.
4. Drug resistance is on the rise due to over use of antibiotics.
5. Rapid Strep tests have been available for over 10 years. They can
give very reliable results within minutes. This have been standard
practice in the United States for ages but is very unpopular with UK
authorities. Could it be because the penicillin is cheaper than the test?
6. There is only weak evidence that treating strep throat with
antibiotics hastens resolution of symptoms but we would like to believe
that it will reduce the presence of secondary complications like Rheumatic
fever and quicy (but not glomerulonephritis).
If you are determined to reduce the over use of antibiotics either do
a culture and wait 24 to 48 hours to treat positive results or do a rapid
strep test and treate positives. Either stratergy will prevent
complications and would be equally efficacious in relieving symptoms. In
the third world or inner city where only relatively ill patients come to
the doctor and compliance is difficult an injection of Pennicillin or
short course of Zithromax is sensible. Once the patients realise that the
complaint of sorethroat is greated with an injection they will be very
judicious of their use of the doctor's services.
Competing interests:
None declared
Competing interests: No competing interests
Do any GPs use their sense of smell when deciding on an antibiotic
prescription? I find that some sore throats smell of decaying flesh,
reminding me of bacteriology practicals, whereas others look red and are
exudative but don't smell. It seems to me from experience that this smell
is associated with streptococcal infections. I have no statistically
significant swab results to confirm this, but if I am weighing up whether
to prescribe, a foul smell will make me decide to give an antibiotic. The
smell isn't just halitosis since it is the same from patient to patient.
Any microbiologists' views on this?
Competing interests:
None declared
Competing interests: No competing interests
Acute Pharyngitis is a leading cause of morbidity in the Paediatric
age group. Although, viruses cause most of them it is not possible to
differentiate this clinically. A throat swab and culture, which is the
gold standard of diagnosis, is not available in most areas in Sri Lanka.
Mitral valve prolapse and other valvular heart lesions as a result of
rheumatic fever is still common in Sri Lanka. Therefore, in economically
deprived countries like Sri Lanka it may be rational to prescribe
antibiotics to all sore throats with view of preventing more serious
complications. However, guidelines should be formed as to which
antibiotics to prescribe in such situations. Some general practitioners
prescribe very expensive antibiotics, mostly to impress the patients who
believe that expensive antibiotics are more effective. Therefore, it is
vital to educate the general public that sore throats can be treated
effectively with cheap antibiotics such as oral penicillin.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
Streptococci are masking, they hide, they are intracellular.
But streptococci still induce post-streptococcal-reactive
diseases. 3 % of untreated strep-throat are followed by rheumatic
sequelae. This number is still the truth.
You have to take a world-wide perspective to understand.
You have to go to Australia, like S. M. Wearne.
She learned in the Outback:
"..practising evidence-based medicine requires that sore throats are
treated with penicillin, not just analgesics."
The same is true in cold Goettingen.
People suffer behind false concepts.
Penicillin is able to eradicate the hidden pathogen.
Sincerely Yours
Friedrich Flachsbart
Lit.: S. M. Wearne: Reflections on a year in the outback
MJA 2002;177:117-118
Competing interests:
None declared
Competing interests: No competing interests
From Sore Throat to Severe Acute Respiratory Syndrome (SARS)
Dear Sir,
the way from "mild sore throat" to systemic inflammatory response
syndrome is sometimes very short.
Streptococcus pyogenes does interact with coagulation, sometimes in a
catastrophic manner.
Yours
Friedrich Flachsbart
H. Herwald, M. Mörgelin, B. Dahlbäck, L. Björck:
Interactions between surface proteins of Streptococcus pyogenes and
coagulation factors modulate clotting of human plasma.
Journal of Thrombosis and Haemostasis 2003;1:284-291
Competing interests:
None declared
Competing interests: No competing interests