Dear Editors,
As co-author of the Belgian guideline on acute sore throat, I find it difficult to agree with this article [Citation1] for several reasons.
In the context of a Centor score 3–4 (McIsaac 3–4 or FeverPain 3–5), the authors suggest that ‘patients should be assured of an adequate dose of paracetamol. If this is not done, fast-acting paracetamol should be administered in the clinic (with an effect within 15–30 minutes). In case of a poor or moderate effect, a throat swab should be obtained and analysed on the spot for the presence of GAS. Antibiotics may be considered if the test is positive.'
It seems that this approach will not be used in most countries and is not very realistic because it is time-consuming, not feasible in a busy practice, incurs the cost of a rapid test and the illness is self-limiting in 95% of cases. Exceptional cases, such as immunocompromised or very sick patients, may benefit from antibiotics.
2.A delayed prescription strategy is mentioned in the guideline, while in many cases this is done to meet the patient’s expectations or the patient’s pressure for antibiotics, but is usually unnecessary. A delayed prescription strategy is often used to end the consultation quickly and limit the time needed to allay the real concerns about the complaint. In our study, discussion of patients’ concerns was correlated with less antibiotic prescribing [Citation2]. The concerns of the patient are not mentioned in the text of Gunnarsson.
3.Gunnarsson’s study places great emphasis on rheumatic fever and rheumatic heart disease (28 times in the text), while the Cochrane review on pharyngitis [Citation3] has not diagnosed a case of acute rheumatic fever since 1975, neither in the antibiotic nor in the placebo group.
4.The authors state: ‘Some policymakers do not recommend antibiotic use, regardless of the presence of GAS, for patients with an uncomplicated acute sore throat, while other policymakers allow limited use. Policymakers need to decide which of these two alternative paths they recommend in their guidelines.'
It is strange that this sentence is only mentioned with an asterisk, but without further references. The guidelines of the Netherlands [Citation4] and Belgium (https://www.domusmedica.be/richtlijnen/acute-keelpijn) [Citation5], clearly state that no additional tests and antibiotics are recommended for acute sore throat. In the exceptional cases, when alarm symptoms are present, urgent referral is necessary, and this is well described by Gunnarsson and colleagues.
5.Even with Centor scores 3–4 or McIsaac 3–4 or FeverPain 3–5 scores, given the high rate of carriage, the probability that the infection is actually caused by streptococci is no more than 50%, equal to tossing a coin.
I could not find conclusive evidence to support the consensus of the authors [Citation1]. Moreover, the proposed guideline still has the risk for overdiagnosis and overprescription in patients with a mostly minor complaint in general practice and has a medicalising effect. It is not certain that this consensus statement will reduce overprescribing of antibiotics.
Matthys Jan, co-author of the Belgian guideline on acute sore throat [Citation5].
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
- Gunnarsson RK, Ebell M, Centor R, et al. Best treatment of patients with acute sore throat – a critical analysis of the current evidence and a consensus of experts from different countries and traditions. Infect Dis. 2023;27:1–12.
- Matthys J, Elwyn G, Van Nuland M, et al. Ideas, concerns and expectations of patients (ICE) in general practice: impact on prescribing. Br J Gen Pract. 2009;59(558):29–36.
- Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev. 2021;12:CD00.
- de Jongh E, Opstelten W. Working group NHG-Standard acute sore throat. Revision of the practice guideline 'acute sore throat’ of the Dutch General Practitioners Society. Ned Tijdschr Geneeskd. 2015;159:A9456.
- Matthys J, De Meyere M, Van Driel M, et al. Differences between international pharyngitis guidelines: not just academic. Ann Fam Med. 2007;5(5):436–443.