1. antibiotic prescribing for sore throat



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CEPP National Audit – Focus on Antibiotic Prescribing

1. ANTIBIOTIC PRESCRIBING FOR SORE THROAT



Background

AWMSG NPI: Antibacterial items per 1,000 STAR-PUs


The development of antibiotic NPIs supports one of the core elements of the Welsh Antimicrobial Resistance Programme: to inform, support and promote the prudent use of antimicrobials.
Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation1:


Illness

Comments

Medicine

Adult dose

Duration of treatment

Acute sore throat

CKS

Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours2A+
If Centor score 3 or 4: (lymphadenopathy; no cough; fever; tonsillar exudate)3A- consider 2 or 3-day delayed or immediate antibiotics1,A+ or rapid antigen test10B+.
Antibiotics to prevent quinsy NNT > 40004B-

Antibiotics to prevent otitis media NNT 2002A+

10d penicillin lower relapse versus 7d in RCT in < 18 yrs8


Phenoxymethylpenicillin5B-

500 mg QDS

1 g BD6A+ (QDS when severe7D)



10 days8A-

Penicillin allergy:

Clarithromycin



250–500 mg BD

5 days9A+


NICE CG69 – Respiratory tract infections

1.3 A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions:

  • acute otitis media

  • acute sore throat/acute pharyngitis/acute tonsillitis

  • common cold

  • acute rhinosinusitis

  • acute cough/acute bronchitis.


Depending on clinical assessment of severity, patients in the following subgroups can also be considered for an immediate antibiotic prescribing strategy (in addition to a no antibiotic or a delayed antibiotic prescribing strategy):

  • bilateral acute otitis media in children younger than 2 years

  • acute otitis media in children with otorrhoea

  • acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria1 are present2.


Method

There is a choice of two methods for identifying cases in this audit:



  • Method 1 searches by Read Code diagnosis; it therefore identifies all patients who presented with a sore throat. The patients may or may not have received an antibiotic and this method will highlight the choice of antibiotic for sore throat. The figure for percentage of patients receiving antibiotics should be interpreted with caution as this will vary considerably depending on the Read Codes audited.

  • Method 2 searches by antibiotic (penicillin) and therefore focuses on patients who have received an antibiotic and the criteria used at the point for prescribing

For both methods, only the most recent episode for an individual patient should be considered. Patients with recurrent throat infections should be excluded where another episode has been diagnosed in the previous eight weeks. Start the searches using a 3-month window and extend it if necessary to reach the required number of cases.


Method 1: Sore throat, search by Read Code diagnosis

Assess a reasonable sample of records with a diagnosis of sore throat (see section on Sample size). To identify the sample, perform a search using an appropriate selection of the following Read Codes:


1C9 Sore throat symptom

1C9-1 Throat soreness

1C92 Has a sore throat

1CB3 Throat pain

194 Swallowing symptoms

1692 Swollen glands

A340 Streptococcal sore throat

H02 Acute pharyngitis

H02-1 Sore throat NOS

H02-2 Viral sore throat NOS

H02-3 Throat infection – pharyngitis

H024 Acute viral pharyngitis

H02z Acute pharyngitis NOS

H03 Acute tonsillitis

H03-1 Throat infection – tonsillitis

H03-2 Tonsillitis

H031 Acute follicular tonsillitis

H036 Acute viral tonsillitis

H03z Acute tonsillitis NOS


Centor criteria:



Score 1 point for each of: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough2.
Following the audit, complete the Review Sheet.
Data collection sheet (Method 1)


Patient

Tonsillar exudate (Y/N)

Lymphadenopathy (Y/N)

Fever (Y/N)

Presence/ absence of cough: not recorded (x) cough present (P) cough absent(A)

All criteria for Centor score recorded? (Y/N)

Centor score 3 or 4? (Y/N)

Antibiotic given? (Y/N)

Criteria met

i.e. No antibiotic prescribed

OR

Immediate/delayed antibiotic + Centor score = 3 or 4? (Y/N)

Delayed/ back up prescribing? (Y/N)

Phenoxy-methylpenicillin or clarithromycin?2 (Y/N)

Other (record name and reason, where given)

Comments










































































































































































































































































































































































































































































































































































































Total





































% Yes





































Standard













100%







90%




95% of prescriptions








Method 2: Sore throat, search by antibiotic (penicillin)

Search for adults and children issued phenoxymethylpenicillin (Penicillin V) and identify the cohort prescribed for throat infection (see section on Sample size).



Following the audit, complete the Review Sheet.
Data collection sheet (Method 2)


Patient

Tonsillar exudate (Y/N)

Lymphadenopathy (Y/N)

Fever (Y/N)

Presence/absence of cough:

not recorded (x) cough present (P) cough absent (A)

All criteria for Centor score recorded? (Y/N)

Delayed/back-up prescription?

Immediate antibiotic given

Centor score = 3 or 4? (Y/N)

Comments

























































































































































































































Total

























% Yes

























Standard













100%




90%






REFERENCES




1 Centor criteria are: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough.

2 Where clarithromycin is suggested erythromycin may be used3.

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