A sore throat is no fun. You want relief and think that a prescription for antibiotics will provide it. But antibiotics are not always the answer.

Pharyngitis may sound like an exotic disease, but in fact it’s very common—so common that it accounts for approximately 11 million visits to doctors’ offices and emergency rooms each year in the U.S.

So what is pharyngitis? It’s a sore throat. (The pharynx is the throat; pharyngitis is inflammation of the pharynx.) In most adults, pharyngitis will get better without treatment. In adults, pharyngitis is usually caused by a virus. Only 10% of cases are caused by bacteria; the most common bacterial cause of pharyngitis that requires treatment is group A beta-hemolytic streptococci.

The ifs and ands of antibiotics

Antibiotics are prescribed to treat pharyngitis. Penicillin, for example, can work quite well, cutting the length of illness by 1 to 2 days and reducing the likelihood of complications. The problem is that antibiotics work only against bacteria, not viruses.

Although only 10% of people with a sore throat (the 10% with bacterial infection) should get antibiotics, 73% of people with a sore throat who see a doctor do receive the drugs. In addition to not being effective against viral pharyngitis, the antibiotics may cause unwanted side effects and lead to the growing problem of antibiotic resistance. In antibiotic resistance, germs that are exposed to antibiotics and not destroyed by the drugs become stronger and harder to kill the next time around.

What’s the score?

Clearly, it’s important to establish whether a person’s pharyngitis is viral or bacterial in order to avoid the inappropriate use of antibiotics. Doctors often begin the screening process using the pharyngitis score. The score evaluates a person for the presence of group A streptococcal pharyngitis, based on 4 factors:

• history of fever
• white patches on the tonsils
• absence of cough
• swollen glands in the neck.

Generally, if a person has none or only 1 of the above symptoms, no further testing or treatment is recommended. But the next step in the process isn’t clear-cut; experts disagree as to when a person should be tested for bacterial infection, the best way to test, and when antibiotics should be prescribed.

In search of the best treatment strategy

In an effort to help settle the debate, a team of researchers in Switzerland compared the following 5 management strategies in 372 adults who had a pharyngitis score of at least 2:

• treatment of symptoms without testing or antibiotics
• rapid streptococcal antigen test (RSAT) for all the study participants, with antibiotics for all persons with positive RSAT results (indicating the bacterial pharyngitis)
• selective RSAT for persons with a pharyngitis score of 2 or 3 and antibiotics for those with a score of 4
• antibiotics without testing in persons with a pharyngitis score of 3 or 4
• testing a specimen from the throat (culture) for all the study participants, with antibiotics for all persons with positive culture results (indicating he bacterial pharyngitis).

The researchers found that the most cost-effective way to treat pharyngitis appropriately and reduce the overuse of antibiotics was to perform RSAT testing for everyone who had at least 2 clinical findings that suggested the presence of group A streptococcal pharyngitis.

The anti-antibiotic approach

The recommendations for diagnosis and management of pharyngitis vary from one expert organization to the next. Just about all these groups are united, however, in reaching one goal: to avoid unnecessary testing and antibiotic use in people who are at low risk for streptococcal pharyngitis. We still have a long way to go on this front. In one study of 2,100 people with pharyngitis, only 17% of them had positive test results for group A streptococcal infection, but 47% were prescribed antibiotics. And, the national rate of prescribing antibiotics to adults who have a sore throat is much higher than necessary.

Next time you seek treatment for a sore throat, don’t be concerned if your doctor doesn’t run tests or give you a prescription for an antibiotic. In all likelihood it simply means that your case of pharyngitis doesn’t qualify for such treatment. Your doctor is most likely complying with guidelines that will eventually help reduce unnecessary testing and antibiotic use.

From Archives of Internal Medicine