Management Approaches

Patient Education

Materials to help healthcare professionals communicate with and educate patients on antibiotic use are available from many national and international bodies, such as the US Center for Disease Control and Prevention (CDC) and the European Centre for Disease Prevention and Control (ECDC).

“Your immune system is equipped to deal with this infection”

These provide advice on consultations and how to manage patient expectations. For example, the US CDC’s guidance on how to communicate with patients about appropriate antibiotic use for upper respiratory tract infection advises:

Prof. van der Velden outlined the most important message for patients with sore throat and respiratory tract infections: “Your immune system is equipped to deal with this infection”.

Advising patients why an antibiotic is not required is hard to convey. Although a healthcare professional may say antibiotics are ineffective against viral infections, this may mean little to the patient. “The differences between viruses and bugs are difficult to explain,” said Prof. Altiner. “There are maybe things we can learn from marketing as there is a difference between cognitive awareness and behaviour”. Getting the antibiotic resistance message across to younger generations is also important, although there was some pessimism. “These types of programmes don’t stop children smoking, drinking or taking drugs when they get older”, Dr Duerden pointed out.

“Around two-thirds of children will get antibiotics, around 89% for sore throat”

Overall it was clear that an easy, understandable message and framework for patients on antibiotic use needs to be created, and this may vary by country. Consistent, sustained messaging across healthcare professionals, spanning both primary and secondary care, is also vital. “We have to communicate but we have to communicate effectively and we have to do it over and over again”, said Mr Bell, citing the example of the Australian sunscreen campaign that has run for over 30 years.

Physician Strategies

A number of strategies have been used to encourage physicians to rationally prescribe antibiotics for sore throat.

“In the private sector, the antibiotic resistance rate is lower but there is a broader range of drugs against which resistance exists because antibiotic choice is unrestricted”

Centor criteria
The Centor criteria feature in a number of national and European guidelines^18-21. These advise that the risk of a bacterial infection is raised if 3–4 Centor criteria are present²¹:

• temperature >38°C
• no cough
• tender anterior cervical adenopathy
• tonsillar swelling or exudate.

In the Netherlands, these criteria are no longer used as a basis for prescription for sore throat. Instead, said Prof. van der Velden the new guideline advises to prescribe for patients with a severe infection, which is characterised by the throat aspect plus the patient’s condition. Reasons to prescribe are:

• severe illness, fever, throat and swallowing complaints that affect daily functioning
• peritonsillar infiltrate or abscess
• extremely swollen, painful lymph nodes across the entire neck and throat region.

Delayed prescribing

In the UK, guidelines recommend either no prescribing, with ‘watchful waiting’, or delayed antibiotic prescribing,¹⁸where patients are given an antibiotic prescription but advised only to have it dispensed if symptoms persist or worsen after a few days. In clinical practice 30% of patients still receive an antibiotic prescription²².

Dr Duerden said: “GPs know delayed prescribing is not very meaningful and it is a bit deceptive, if antibiotics are unnecessary but they still do it. A better strategy may be to see the patient again if symptoms persist”.

Physician Guidance

While a number of national and regional guidelines are available on sore throat management, these often differ between countries and are subject to change. Prof. Pignatari pointed out: “There are guidelines for smaller countries, but what are the options for larger countries? These should be adapted for the BRIC [Brazil, Russia, India, China] countries and for countries where no guidelines exist”.

“If I dissuade them from having an antibiotic in primary care, they then should not be able to go to another GP or their accident and emergency department and get one”

In countries where guidelines do exist, such as Germany, the Netherlands and the UK, there remains irrational prescribing. “GPs will say guidelines are for average patients, but my patients are not average”, explained Prof. van der Velden.

Prof. Essack called for the group to create a framework for nonantibiotic use, rather than a guideline, that was adaptable across countries and cultures. This framework should encompass advice to patients and consider other strategies to manage sore throat, cough and other respiratory tract infections.

Symptom Management

Sore throat is one of the leading indications for antibiotic use in many countries, despite up to 95% of sore throat infections being of viral origin^{24, 25}. Multiple strategies can be considered to help physicians determine appropriate use and improve patient management.

“GPs will say guidelines are for average patients, but my patients are not average”

For patients, managing persistent or worsening symptoms is the key reason to seek physician treatment¹¹. The group suggested the following good practice approaches that can also be adapted to other upper respiratory tract infections: