Antibiotics for sore throat? No shame allowed

Shame is not an effective way to change behavior. In the face of shame, one may emotionally shut down or become angry and defensive. We need to start this discussion by believing that we do a fantastic job every day for our patients, and that we went into medicine because we are compassionate and empathic people. We are enough just by showing up at work and doing what we do.

But we can always improve.

Starting from here, we need to remind ourselves that viruses are the cause of 90% of sore throats. The prevalence of group A Streptococcus (GAS) infection is approximately 10%. GAS would be the only cause of sore throat requiring antibiotics.

The antibiotic prescribing rate for adults with sore throat was 70% in 1993. Using national survey data, Dr. Michael Barnett and Dr. Jeffrey Linder reported that physicians prescribed antibiotics for sore throat at 60% of primary care and emergency department visits (95% CI: 57%-63%). The use of broad-spectrum antibiotics such as azithromycin was common despite the fact that GAS is universally susceptible to penicillin. Penicillin was given in only 9% of visits (JAMA Internal Medicine 2013 [doi:10.1001/jamainternmed.2013.11673]).

Adverse consequences of antibiotic prescribing are not uncommon. The Clostridium difficile diarrhea and colitis that we are seeing in our practice is not only becoming more prevalent, but much more difficult to treat. Telling patients that they can develop C. difficile colitis should become a routine part of side effect discussions when prescribing antibiotics.

And, although we may recommend the use of probiotics for patients to prevent both antibiotic-associated and C. difficile diarrhea (CDD), a large study of adults aged 65 and older suggested that a multistrain preparation of lactobacilli and bifidobacteria was not effective in the prevention of antibiotic-associated diarrhea or C. difficile diarrhea (Lancet 2013;382:1249-57).

So, our challenge is that patients come in and demand antibiotics. But most do not have a real understanding of the risks to them personally and to the population at large through the indiscriminate use of antibiotics.

In a non-shame–based manner, we need to teach them.

Telling them that symptoms resolve in 40% of patients within 3 days and 80% of patients within 1 week, irrespective of whether the cause was viral or streptococcal, may be helpful. The use of a clinical decision aid for sore throat may also be helpful.

Many may be familiar with the clinical scoring algorithm known as the "Centor Criteria." The criteria consist of four findings that are each assigned one point: history of fever, absence of cough, tender or swollen lymph glands in the neck, and red and tonsillar exduates.* Patients with zero or one finding do not require testing or antibiotics. Patients with two or three findings should have a rapid strep test performed, and the results should guide antibiotic treatment. Patients with four findings should receive antibiotics.

This algorithm is available in the incredibly useful MedCalc medical calculator app in the iTunes store.

We need to keep telling ourselves that we have nothing to be ashamed about by currently prescribing too many antibiotics for adults with sore throat – and that we can and will do better.

Dr. Ebbert is professor of medicine, a general internist, and a diplomate of the American Board of Addiction Medicine who works at the Mayo Clinic in Rochester, Minn. The opinions expressed are those of the author.

*Correction, 1/3/2014: An earlier version of this story misstated the Centor Criteria.