Preventing resistance requires antibiotics to be used only when necessary. While many antibiotic campaigns focus on differentiating between infections of bacterial and viral origin, Prof. Altiner was unconvinced this was the right approach.
“It’s not taking the patient seriously to say it’s just a virus”
Dr van der Velden added that the policy in the Netherlands was to manage illness based on the seriousness of the infection, rather than on the basis of viral or bacterial origin.
Prof. Altiner concurred that the healthcare professional should focus on excluding the risk of serious infection. Dr Duerden pointed out that it often did not matter if the infection was bacterial in nature, as “people will get better without treatment.”
The panel agreed that the key to preventing resistance when treating respiratory tract infections was to reserve antibiotic use for serious bacterial infections and for patients with increased risk of complications. Determining what is a serious infection required further consideration, however. For example, emerging data show 46% of doctors cannot accurately predict the cause of a sore throat based on a physical examination.8
In sore throat, the Centor criteria provide an immediate gauge of the likelihood of the risk of Group A beta-haemolytic Streptococcus, or Strep throat infection, which can have serious complications, but the accuracy of the result was not perfect. Dr Duerden pointed out that the risk of serious consequences was much reduced in the 30 years since the Centor criteria had been introduced.
Opinions were divided as to whether modified Centor criteria taking into account age under 15 years and over 45 years would be more useful in aiding treatment of a potential Strep throat. In addition, certain other patient groups at increased risk of infection should be considered, such as the immunocompromised, those with HIV, those who have underlying disease or specific local populations, e.g. Aboriginal or Torres Strait Islanders in Australia. Dr Duerden advocated that healthcare professionals should be alert for frail patients, who often have underlying disease.
Using the Centor criteria in conjunction with a Strep test would be of value. New research shows that of those cases confirmed with culture as Group A Streptococcus, physicians correctly identified 27% (11/40) of cases. Physicians correctly believed Group A Streptococcus was unlikely in 32% (133/401) of all cases and a further 18% (74/401) of all cases were diagnosed incorrectly as likely or very likely due to Group A Streptococcus. For 46% (183/401) of cases, physicians were uncertain whether Group A Streptococcus was the cause.8 It was recommended that testing should only be undertaken where a positive response would change management, but Dr Pignatari added that, in countries where antibiotic prescribing rates are high, testing can be instrumental in dissuading doctors from prescribing.
Providing guidance on the normal duration of the various respiratory tract infections and offering alerts on worsening and red flag symptoms was also recommended, to ensure concerns around secondary infections could be addressed. Other factors to consider were frequency of infection, criteria for tonsillectomy and current epidemics.
Factors to Consider in Managing Sore Throat
- The evidence base for treatment options for sore throat, including non-drug options.
- Patients’ discomfort, treatment, desires (e.g. rapid relief) and worries. A range of formats to suit individual preference, such as oral analgesics, local analgesics, lozenges, sprays, gargles. Often the preference is driven by culture and drug availability in each country.
- Adopting a flexible approach to suggested treatments, within the confines of the self-limiting nature of sore throat, to find the one that best meets individual needs.
Factors to Consider in Preventing Resistance
- Reserve antibiotic use for serious infections. Determine the risk of serious infection by identifying and excluding red flag signs and symptoms.
- Be alert to those patients at increased risk of complications of a respiratory infection, e.g. people who are immunocompromised, those with HIV, frail patients, young children, patients with relevant co-morbidities.
- Testing for bacterial infections is not a necessity, but can have merit in some cultural settings as a means of guiding doctors’ prescribing behavior and facilitating discussion about nonantibiotic treatment.
- Provide patients with guidance on when to return for further investigation to identify secondary infections or deteriorating infections.