What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies

Abstract

Objective: Identifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings.

Design: We compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare.

Setting and participants: The nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies.

Main outcome measures: The proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to.

Results: In a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3-4 Centor scores (or 2-3 FeverPAIN scores or 3-4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%-15% of patients and prescribing antibiotics to only 3.5%-6.6%.

Conclusions: Patients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.

Keywords: primary care; protocols & guidelines; public health.