Chapter 10 - part 3
Illustrative patient pathway to self care

Alarm symptoms or signs (red flags)

Quinsy

Symptoms include a worsening sore throat, usually on one side, with fever, difficulty opening the mouth, difficulty swallowing, drooling rather than swallowing their own saliva and sometimes swelling of the face and neck. It requires urgent medical assessment and, if confirmed, rapid referral to hospital for surgical drainage.

Epiglottitis

The first symptoms are a high temperature and rapid onset of a very sore throat. Severe difficulty in swallowing follows, with drooling, spitting, fast and very noisy breathing. A child will sit straight upright in order to help them breathe more easily, or may sit with their chin forward. In infants there may be problems with sucking when breast or bottle feeding.

As the epiglottis swells and blocks the airways, a child may find it hard to breathe, and their skin may turn grey or blue. They may be restless and panicky, and have fever or shivering attacks. They may be unable to speak or have a very muffled voice, make grunting type noises and sit leaning forward, trying to keep their airways open. Never lie the child down or try to look in their throat, as this can trigger a spasm that closes their throat completely, and can cause death within a few minutes. In adults, symptoms are similar, but they start more gradually and recovery is usually slower. The main symptom is usually severe pain that is worse on swallowing.

This condition is an emergency, and you should phone 999 for an emergency ambulance, or get the affected person to the nearest A&E department.

Agranulocytosis

The commonest causes are drug reactions or infections in already immunocompromised patients. Patients taking drugs commonly associated with this adverse reaction should have received warnings to report sore throats promptly, and need medical evaluation.

Other diagnoses

Glandular fever

Sore throat with fever, feeling unwell generally, and swollen glands in the neck, armpit and groin may suggest glandular fever, otherwise known as infectious mononucleosis or Epstein–Barr virus (EBV). Abdominal pain and a rash may also occur and the spleen may be enlarged. A blood test can confirm the diagnosis and symptomatic treatment advised.

Scarlet fever

The main symptoms include sore throat with fever, headache, vomiting and swollen neck glands. The tongue has a thick white coating that peels to leave a red ‘strawberry’ appearance. The rash usually appears on the second day and looks like sunburn. You can feel little bumps all over it and it may be itchy. It appears on the neck, and spreads to the rest of the body. The skin affected may peel off, especially around the fingers and toes. The causative agent is the toxin produced by the group A beta-haemolytic streptococcus (GABHS).

Persistent sore throat

Consider other diagnoses such as perennial or seasonal rhinitis with postnasal catarrh, and, rarely, blood abnormalities like leukaemia.

Late complications

Other complications of acute sore throat caused byGABHS are sinusitis or otitis media. Non-suppurative complications include acute nephritis and rheumatic fever, both now very rare in developed countries.

Identifying GABHS

Throat swab cultures can take 24-48 hours to be reported, limiting their usefulness for a decision during the consultation. The high rate of asymptomatic carriers in the population of around 40% means that many people with a positive throat culture will not have a sore throat caused by GABHS.5 Rapid antigen testing gives a quick result in the consultation, but still only tells you if GABHS is present, not if it is the cause. Neither is much help with deciding on whether to treat with antibiotics!

A symptom and sign score such as the Centor score may help to decide whether GABHS is present using the criteria:8,9

tonsillar exudates
tender anterior cervical lymph nodes
fever
absence of cough.

A score of 0, 1 or 2 of the criteria shows low likelihood of GABHS infection; a score of 3 or 4 of the criteria increases the likelihood of GABHS infection.

Using antibiotics

Astudy in children using two of the Centor criteria as the cut off point for treating with antibiotics showed that antibiotics did not help the symptoms but did reduce the complications of imminent quinsy, impetigo and scarlet fever.10 However, the authors did not advise immediate prescription of antibiotics even for this group of children who were more unwell. Delayed antibiotic use in children whose illness worsened was sufficient.Acommentary on this and other studies concluded that seven children with two of the four Centor criteria would have to be treated to prevent one case of worsening of illness.11 The other six would suffer the disadvantages of side-effects, reduced local and systemic immunity and the cycle of recurrence.

A systematic review by the Cochrane Collaboration suggested that antibiotics might shorten the length of time symptoms persisted, but only by eight hours overall.12 Around 90% of patients were symptom free after seven days, whether or not they received antibiotics. There was no evidence that treatment with antibiotics resulted in an earlier return to school or work. The review also reported that, although antibiotic treatment reduced the incidence of otitis media and sinusitits, this did not translate into significant clinical benefits. To prevent one episode of otitis media, about 30 children and 145 adults with sore throat would need to be treated with antibiotics.

Other studies have reported the lack of success in preventing both rheumatic fever and acute glomerulonephritits when sore throats were treated with antibiotics. Most clinical trials have used 10 days of penicillin or erythromycin to eradicate GABHS. It is not clear if shorter courses are any less effective in relieving symptoms or preventing complications.5 Other antibiotics such as amoxicillin should be avoided because of the risk of precipitating a rash if the patient has glandular fever.

The MeRec Bulletin and the SIGN guidelines both conclude that GPs should avoid prescribing antibiotics for most sore throats.5,6 In very ill patients, or those with a history of previous complication, penicillin or erythromycin may be used. A delayed prescription, to be used if symptoms worsen after a few days, may be a useful compromise for patients unconvinced by an explanation of the evidence. There are two models for a ‘delayed’ prescription: one where the patient comes back to the practice if the condition persists,13 and the other where a post-dated prescription is given.14 In any audit you undertake of your prescribing for sore throats, you should develop a system to account for delayed antibiotic prescriptions not presented to the pharmacy because the person’s sore throat symptoms have resolved. If the prescription is left at the practice to collect, you should delete it as having been issued, on your computer system. If you opt for the post-dated delayed prescription model, see if you can allocate a specific code for delayed prescriptions via your practice computer system.

Apart from being mainly unnecessary or ineffective for sore throat, prescribing antibiotics can trigger a learnt behaviour resulting in future unnecessary consultations.

Find a way to gain everyone’s agreement on your policy for prescribing antibiotics in general, and in this instance for sore throat - and review the extent to which all prescribers are adhering to your practice policy. Advertise that message to patients so they know when they should consult a doctor or nurse with their sore throat or when

they might benefit from an antibiotic. This might be a central part of establishing a local minor ailments scheme in pharmacies and general practices (see Chapter 6).

References

1 www.nhsdirect.nhs.uk/SelfHelpGuide

2 www.prodigy.nhs.uk

3 www.sign.ac.uk/guidelines/fulltext/34/annex2.html

4 Department of Health. Antibiotics: don’t wear me out. London: Department of Health; 2005. www.dh.gov.uk/assetRoot/04/05/71/75/04057175.pdf

5 National Prescribing Centre. Managing sore throats. MeReC Bulletin. 1999; 10 (11).

6 SIGN. Management of Sore Throat and Indications for Tonsillectomy: a national clinical guideline. Report No. 34. Edinburgh: Scottish Intercollegiate Guidelines Network; 1999. www.sign.ac.uk

7 Prodigy guidance: www.prodigy.nhs.uk/pk.uk/sore_throat_acute/

8 McIsaac W, White D, Tannenbaum D and Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. Canadian Medical Association Journal. 1998; 158: 75–83.

9 McIsaac W, Goel V, To T and Low DE. The validity of a sore throat score in family practice. Canadian Medical Association Journal. 2000; 163: 811-15.

10 Zwart S, Poever MM, de Melker RA et al. Penicillin for acute sore throat in children: randomised, double blind trail. British Medical Journal. 2003; 327: 1324–7.

11 Little P. More valid criteria may be needed. British Medical Journal. 2003; 327: 1327-8.

12 Del Mar CB and Glasziou PP. Antibiotics for sore throat (Cochrane Review). The Cochrane Library, Issue 3. Oxford: Update Software; 1999.

13 Little P, Williamson I, Warner G et al. Open randomised trial of prescribing strategies in managing sore throat. British Medical Journal. 1997; 314: 722-7.

14 Edwards M, Dennison J and Sedgwick P. Patients’ responses to delayed antibiotic prescription for acute upper respiratory tract infections. British Journal of General Practice. 2003; 53: 845–50.

part 2

part 1

Chapter 10 - part 3 Illustrative patient pathway to self care