Question

Are antibiotics effective for treating patient symptoms and reducing potential complications associated with sore throat?

Relevance to nursing care

Sore throat is a common complaint presented in primary care. Although the causative agent for sore throat may be viral or bacterial, it is difficult to differentiate between the two causes using only signs and symptoms. The most common cause of a sore throat is a virus, but a bacterial infection, especially group A beta-hemolytic Streptococcus (GABHS), is critical to rule out. If not treated appropriately, GABHS may contribute to rare but serious complications that can be divided into suppurative complications [i.e. peritonsillar abscess (quinsy), otitis media and sinusitis] and non-suppurative complications (i.e. acute rheumatic fever and acute glomerulonephritis). The value of antibiotics is to reduce suppurative and non-suppurative complications. In many cases, GABHS pharyngitis is self-limiting and resolves within a few days without treatment; however, antibiotics will shorten the duration of symptoms.

Study characteristics

This is a Cochrane review1 containing a meta-analysis of 27 randomized control trials (RCTs) completed from 1951 through 2003. The majority of the studies were conducted in the 1950s and there were no new studies published after 2003. All of the studies were placebo-controlled trials, which sought to determine if antibiotics helped reduce symptoms of sore throat, fever and headache, or the occurrence of serious complications.

This review contained 27 RCTs involving 12 835 cases that assessed the benefits of antibiotics in the management of sore throat. Antibiotics significantly reduced the symptoms of sore throat [odds ratio (OR) 0.68, 95% confidence interval (CI) 0.59-0.78], headache (OR 0.44, 95% CI 0.27-0.71) and fever (OR 0.71, 95% CI 0.45-1.10) at day 3 compared with placebo. In addition, antibiotics significantly reduced the incidence of complicating otitis media in patients with sore throat (OR 0.30, 95% CI 0.15-0.58) and acute sinusitis (OR 0.48, 95% CI 0.08-2.76), compared with placebo. There were few studies related to non-suppurative complications (glomerulonephritis and acute rheumatic fever); therefore, the authors could not claim that antibiotics protected patients with sore throat from these complications. Because complication rates are low and sore throat is a short-term, self-limiting illness, the absolute benefit of using antibiotics is small.

Implications for nursing care

The quality of the evidence in the review is considered to be moderate to high. The review authors found that antibiotics did shorten the duration of symptoms, but only by an average of about 1 day. Therefore, the effect of antibiotics on reducing symptoms of sore throat was small. Because the effect on symptoms is small, clinicians should evaluate each case individually as to whether it is clinically justifiable to employ antibiotics to produce this effect. Regardless of treatment with or without antibiotics, 90% of the patients are symptom-free by 1 week. Antibiotics have a beneficial effect on both suppurative and symptom reduction. Because there were few studies that included children (younger than 13 years of age), there were insufficient data to draw conclusions about children.

Implications for research

Clinical trials are needed in low-income countries, in socio-economically deprived areas of high-income countries and in children to determine if antibiotics help to reduce symptoms of sore throat, fever and headache, or the occurrence of serious complications in these populations. Research is also needed on the measurement of severity of symptoms to determine to what extent antibiotics reduce the severity of sore throat. Because the majority of trials were conducted prior to 1975 and only three trials were published since 2000, it is unknown whether changes in bacterial resistance and population immunity over time may have altered the applicability of the results. Prognostic studies that can predict which patients may develop suppurative and non-suppurative complications are also needed.

Reference