Clinical Question

Which signs and symptoms can clinicians rely on to predict which adult patients will develop sore throat complications?

Bottom Line

First, the good news. Complications of acute sore throat—peritonsillar abscess, otitis media, sinusitis, and skin infections—occur in only approximately 1% of adults. However, there is no good predictor of which adults will develop these complications. Decision tools that try to predict a response to antibiotics (e.g., Centor criteria) do not identify patients at risk of complications. In this study, antibiotic treatment was not associated with a lower likelihood of, or the severity of, complications. (Level of Evidence = 1b)

Synopsis

This study was conducted in general practices throughout the United Kingdom in which fewer than 50% of patients with tonsillitis were prescribed antibiotics. The researchers enrolled 14,610 adults presenting with acute sore throat as the main symptom, with an abnormal examination result of the pharynx but without complications at the time of presentation. Overall, 56% of patients were prescribed antibiotics. Complications were assessed in patients who sought additional care within one month with new or unresolved symptoms. The entire cohort was analyzed together (regardless of antibiotic use), with the researchers assuming that antibiotic treatment would attenuate the severity of, but not completely prevent, complications.

Complications—peritonsillar abscess (quinsy), otitis media, sinusitis, impetigo, or cellulitis—occurred in approximately 1% of patients, regardless of whether they received immediate or delayed antibiotics or were not given antibiotics. In multivariate analysis, severe tonsillar inflammation and severe earache were predictive of complications, but not strongly so, and 70% of complications occurred when neither was present. Similarly, a Centor score of at least 4 had a positive predictive value for complications of only 1.7% and the FeverPAIN score was similarly not helpful (positive predictive value = 2.1%). Most complications occurred in patients who had low scores on both predictors or who had bacterial complications. Testing for group A beta-hemolytic streptococcal infection was not performed in most patients. Systemic complications, such as glomerulonephritis and rheumatic heart disease, were not reported.

Study design: Cohort (prospective)

Funding source: Foundation

Setting: Outpatient (primary care)

Reference: LittlePStuartBHobbsFDet alDESCARTE investigators Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ.2013; 347: f6867.