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. 2021 Dec 9;12(12):CD000023.
doi: 10.1002/14651858.CD000023.pub5.

Antibiotics for treatment of sore throat in children and adults

Anneliese Spinks  1 , Paul P Glasziou  2 , Chris B Del Mar  2
Affiliations

Antibiotics for treatment of sore throat in children and adults

Anneliese Spinks et al. Cochrane Database Syst Rev. .

Abstract

Background: Sore throat is a common reason for people to present for medical care and to be prescribed antibiotics. Overuse of antibiotics in primary medicine is a concern, hence it is important to establish their efficacy in treating sore throat and preventing secondary complications. OBJECTIVES: To assess the effects of antibiotics for reducing symptoms of sore throat for child and adult patients.

Search methods: We searched CENTRAL 2021, Issue 2, MEDLINE (January 1966 to April week 1, 2021), Embase (January 1990 to April 2021), and two trial registries (searched 6 April 2021).

Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications amongst children and adults seeking medical care for sore throat symptoms.

Data collection and analysis: We used standard methodological procedures as recommended by Cochrane. Two review authors independently screened studies for inclusion and extracted data, resolving any differences in opinion by discussion. We contacted the trial authors from three studies for additional information. We used GRADE to assess the certainty of the evidence for the efficacy of antibiotics on our primary outcomes (sore throat at day three and one week) and secondary outcomes (fever and headache symptoms and incidence of acute rheumatic fever, acute glomerulonephritis, acute otitis media, acute sinusitis, and quinsy).

Main results: We included 29 trials with 15,337 cases of sore throat. The majority of included studies were conducted in the 1950s, during which time the rates of serious complications (especially acute rheumatic fever) were much higher than today. Although clinical antibiotic trials for sore throat and respiratory symptoms are still being conducted, it is unusual for them to include placebo or 'no treatment' control arms, which is a requirement for inclusion in the review. The age of participants ranged from younger than one year to older than 50 years, but most participants across all studies were adults. Although all studies recruited patients presenting with symptoms of sore throat, few of them distinguished between bacterial and viral aetiology. Bias may have been introduced through non-clarity in treatment allocation procedures and lack of blinding in some studies. Harms from antibiotics were poorly or inconsistently reported, and were thus not quantified for this review. 1. Symptoms Throat soreness and headache at day three were reduced by using antibiotics, although 82% of participants in the placebo or no treatment group were symptom-free by one week. The reduction in sore throat symptoms at day three (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.60 to 0.80; 16 studies, 3730 participants; moderate-certainty evidence) was greater than at one week in absolute numbers (RR 0.50, 95% CI 0.34 to 0.75; 14 studies, 3083 participants; moderate-certainty evidence) due to many cases in both treatment groups having resolved by this time. The number needed to treat for an additional beneficial outcome (NNTB) to prevent one sore throat at day three was less than six; at week one it was 18. Compared with placebo or no treatment, antibiotics did not significantly reduce fever at day three (RR 0.75, 95% CI 0.53 to 1.07; 8 studies, 1443 participants; high-certainty evidence), but did reduce headache at day three (RR 0.49, 95% CI 0.34 to 0.70; 4 studies, 1020 participants; high-certainty evidence). 2. Suppurative complications Whilst the prevalence of suppurative complications was low, antibiotics reduced the incidence of acute otitis media within 14 days (Peto odds ratio (OR) 0.21, 95% CI 0.11 to 0.40; 10 studies, 3646 participants; high-certainty evidence) and quinsy within two months (Peto OR 0.16, 95% CI 0.07 to 0.35; 8 studies, 2433 participants; high-certainty evidence) compared to those receiving placebo or no treatment, but not acute sinusitis within 14 days (Peto OR 0.46, 95% CI 0.10 to 2.05; 8 studies, 2387 participants; high-certainty evidence). 3. Non-suppurative complications There were too few cases of acute glomerulonephritis to determine whether there was a protective effect of antibiotics compared with placebo against this complication (Peto OR 0.07, 95% CI 0.00 to 1.32; 10 studies, 5147 participants; low-certainty evidence). Antibiotics reduced acute rheumatic fever within two months when compared to the control group (Peto OR 0.36, 95% CI 0.26 to 0.50; 18 studies, 12,249 participants; moderate-certainty evidence). It should be noted that the overall prevalence of acute rheumatic fever was very low, particularly in the later studies.

Authors' conclusions: Antibiotics probably reduce the number of people experiencing sore throat, and reduce the likelihood of headache, and some sore throat complications. As the effect on symptoms can be small, clinicians must judge on an individual basis whether it is clinically justifiable to use antibiotics to produce this effect, and whether the underlying cause of the sore throat is likely to be of bacterial origin. Furthermore, the balance between modest symptom reduction and the potential hazards of antimicrobial resistance must be recognised. Few trials have attempted to measure symptom severity. If antibiotics reduce the severity as well as the duration of symptoms, their benefit will have been underestimated in this meta-analysis. Additionally, more trials are needed in low-income countries, in socio-economically deprived sections of high-income countries, as well as in children.

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Conflict of interest statement

Anneliese Spinks has declared that they have no conflict of interest.

Paul Glasziou is on the board of Therapeutic Guidelines Limited and holds a research grant from the National Health and Medical Research Council on antibiotic resistance.

Chris Del Mar has received funding from the National Health and Medical Research Council for antibiotic resistance and from the Cochrane Acute Respiratory Infections Group and some consultancies (GSK for advice about vaccines for otitis media, and a local pharmaceutical company contemplating analgesic ear drops for otitis media).

Figures

1
1
Study flow diagram for the 2021 review update.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Funnel plot of comparison: 1 Antibiotics versus control for the treatment of sore throats: symptom of sore throat, outcome: 1.1 Symptom of sore throat on day 3.
5
5
Funnel plot of comparison: 1 Antibiotics versus control for the treatment of sore throat: symptom of sore throat, outcome: 1.6 Symptom of sore throat at 1 week (6 to 8 days).
6
6
Funnel plot of comparison: 4 Antibiotics versus control for the treatment of sore throat: incidence of complications, outcome: 4.1 Incidence of acute rheumatic fever within 2 months. Rheumatic fever defined by clinical diagnosis.
7
7
Funnel plot of comparison: 4 Antibiotics versus control for the treatment of sore throat: incidence of complications, outcome: 4.4 Incidence of otitis media within 14 days. Otitis media defined by clinical diagnosis.
1.1
1.1. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 1: Symptom of sore throat on day 3
1.2
1.2. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 2: Symptom of sore throat on day 3: early (pre‐1975) versus late studies (post‐1975)
1.3
1.3. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 3: Symptom of sore throat on day 3: blind versus unblinded studies
1.4
1.4. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 4: Symptom of sore throat on day 3: antipyretics versus no antipyretics
1.5
1.5. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 5: Symptom of sore throat on day 3: GABHS‐positive throat swab, negative swab, untested/inseparable
1.6
1.6. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 6: Symptom of sore throat at 1 week (6 to 8 days)
1.7
1.7. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 7: Symptom of sore throat at 1 week (6 to 8 days): early (pre‐1975) versus late (post‐1975)
1.8
1.8. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 8: Symptom of sore throat at 1 week (6 to 8 days): blind versus unblinded studies
1.9
1.9. Analysis
Comparison 1: Antibiotics versus control for the treatment of sore throat: symptoms of sore throat, Outcome 9: Symptom of sore throat at 1 week (6 to 8 days): GABHS‐positive throat swab, GABHS‐negative swab
2.1
2.1. Analysis
Comparison 2: Antibiotics versus control for the treatment of sore throat: symptoms of fever, Outcome 1: Symptom of fever on day 3
2.2
2.2. Analysis
Comparison 2: Antibiotics versus control for the treatment of sore throat: symptoms of fever, Outcome 2: Symptom of fever on day 3: blinded versus unblinded studies
2.3
2.3. Analysis
Comparison 2: Antibiotics versus control for the treatment of sore throat: symptoms of fever, Outcome 3: Symptom of fever on day 3: children compared with adults
2.4
2.4. Analysis
Comparison 2: Antibiotics versus control for the treatment of sore throat: symptoms of fever, Outcome 4: Symptom of fever at 1 week (6 to 8 days)
3.1
3.1. Analysis
Comparison 3: Antibiotics versus control for the treatment of sore throat: symptoms of headache, Outcome 1: Symptom of headache on day 3
3.2
3.2. Analysis
Comparison 3: Antibiotics versus control for the treatment of sore throat: symptoms of headache, Outcome 2: Symptom of headache on day 3: blinded versus unblinded studies
4.1
4.1. Analysis
Comparison 4: Antibiotics versus control for the treatment of sore throat: incidence of complications, Outcome 1: Incidence of acute rheumatic fever within 2 months. Rheumatic fever defined by clinical diagnosis
4.2
4.2. Analysis
Comparison 4: Antibiotics versus control for the treatment of sore throat: incidence of complications, Outcome 2: Incidence of acute rheumatic fever within 2 months. Penicillin versus placebo
4.3
4.3. Analysis
Comparison 4: Antibiotics versus control for the treatment of sore throat: incidence of complications, Outcome 3: Incidence of acute rheumatic fever within 2 months: early (pre‐1975) versus late studies (post‐1975)
4.4
4.4. Analysis
Comparison 4: Antibiotics versus control for the treatment of sore throat: incidence of complications, Outcome 4: Incidence of otitis media within 14 days. Otitis media defined by clinical diagnosis
4.5
4.5. Analysis
Comparison 4: Antibiotics versus control for the treatment of sore throat: incidence of complications, Outcome 5: Incidence of otitis media within 14 days: early (pre‐1975) versus late studies (post‐1975)
4.6
4.6. Analysis
Comparison 4: Antibiotics versus control for the treatment of sore throat: incidence of complications, Outcome 6: Incidence of sinusitis within 14 days. Sinusitis defined by clinical diagnosis
4.7
4.7. Analysis
Comparison 4: Antibiotics versus control for the treatment of sore throat: incidence of complications, Outcome 7: Incidence of quinsy within 2 months. Quinsy defined by clinical diagnosis
4.8
4.8. Analysis
Comparison 4: Antibiotics versus control for the treatment of sore throat: incidence of complications, Outcome 8: Incidence of acute glomerulonephritis within 1 month. Acute glomerulonephritis defined by clinical diagnosis
See this image and copyright information in PMC

Update of

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