MEDICAL MATTERS:Only 30 per cent of sore throats are due to a bacteria, which means only 30 per cent should be treated with an antibiotic, writes DR CHARLES DALY.
“Treat a sore throat with antibiotics and it will be better in a week. Do nothing and it will be gone in seven days.”
– Anonymous
SORE THROAT, one of the most common presentations in general practice, is usually an unpleasant, painful, self-limiting condition of little consequence. Yet the treatment of this seemingly mundane ailment is a microcosm of the uncertainties and challenges encountered in general practice.
As a child, my father had a traumatic experience when one day the local GP/surgeon walked into the kitchen and without warning inserted a primitive guillotine-like device into the back of his throat, emerging with two pieces of bloodied tissue which may or may not have been his tonsils.
My own tonsils were removed, after several bouts of painful ear infection, in the more sophisticated environment of Temple Street Children’s Hospital. My sister had a post-tonsillectomy haemorrhage, the only occasion I can recall an ENT surgeon doing a house call (he was a family friend). The next generation, including my son and several nephews, has had its own troubles with tonsils and earaches.
Some 70 per cent of sore throats are due to viral infection, and the remainder are caused by various bacteria, of which the most common is the Streptococcus species.
In theory, the treatment could not be simpler. If it’s bacterial, use antibiotics and analgesics; if it’s viral, treat only the symptoms. A throat swab will identify a bacterial cause in a few days. In practice, it’s anything but simple. Few sufferers have the patience to wait days for appropriate treatment, and few doctors have the time and enthusiasm to swab every sore throat they see. Treatment is often on a “best-guess” basis and even that has its imperfections.
A minimally red sore throat with blisters may suggest a viral origin but be full of bacteria, whereas a sore throat with tonsils covered in a filthy exudate may turn out to be glandular fever – a viral illness where antibiotic use can cause unpleasant side effects.
Two generations ago, a sore throat could herald the onset of diphtheria, a disease which had a significant mortality especially in children. With immunisation, this condition is almost unheard of in western Europe, but still lurks in areas of Eastern Europe and the Middle East where public health services are not as developed as ours, or may have broken down, so high levels of immunisation are important for continued protection.
There may be a folk memory at work here confounding attitudes of both doctors and patients to the treatment of sore throat.
John Howie, emeritus professor of general practice at Edinburgh University, has demonstrated this confusion in a series of slides of sore throats shown to groups of GPs.
The doctors were shown repeated pictures of the same sore throat, but with differing social scenarios: for example, a sore throat with minimal symptoms; a sore throat in an 18-year-old girl starting her A-levels the next day; a sore throat in a young man going for an important job interview next week; a sore throat in a child with a history of repeated tonsillitis; or a sore throat in your last patient on Friday evening who lives 10 miles from the nearest pharmacy.
They were then asked how many of them would treat with antibiotics. Not surprisingly, the prescribing threshold was reduced significantly as the social situation became more complicated. It would be a very hard-hearted doctor indeed who would refuse such treatment in the interests of microbiological accuracy, but misplaced compassion can have its disadvantages.
Antibiotics are vastly over-prescribed in general practice, hospital medicine and veterinary practice with the development of bacterial resistance now a frightening reality, MRSA being just one of many drug-resistant bacteria causing havoc in medical practice. Antibiotic use in the European Union is decreasing, with Ireland one of the few countries countering this trend.
The treatment of sore throat is one such area where rational use of antibiotics can be slowly promoted. GPs who know their patients well can use their judgment to predict who is more likely to need antibiotics and offer provisional prescriptions to patients to be used only if symptoms persist or deteriorate. Follow-up studies have shown that many of these prescriptions are never cashed and the sore throats presumably clear up with analgesics, lozenges and home-made toddies, which are much cheaper and much more palatable!
Dr Charles Daly is a GP in Co Waterford