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Sore throat - acute - Management
Which antibiotic should I prescribe for sore throat?
- Prescribe phenoxymethylpenicillin for 10 days.
- If the person is allergic to penicillin, prescribe erythromycin or clarithromycin for 5 days.
- Avoid prescribing broad-spectrum penicillins (such as amoxicillin and ampicillin) for the blind treatment of a sore throat.
Basis for recommendation
These recommendations are based on those issued by the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 1999], the Royal College of Paediatrics and Child Health (RCPCH) [RCPCH, 2000], and the Health Protection Agency [HPA and Association of Medical Microbiologists, 2010].
- Phenoxymethylpenicillin remains the treatment of choice compared with other antibiotic options, based on the combination of its proven efficacy, narrow spectrum, safety, and low cost [SIGN, 1999; RCPCH, 2000; Bisno, 2001; MeReC, 2006; HPA and Association of Medical Microbiologists, 2010].
- A 10–day treatment course with phenoxymethylpenicillin is generally recommended [SIGN, 1999; RCPCH, 2000; MeReC, 2006; HPA and Association of Medical Microbiologists, 2010]. This is to ensure the maximal rate of eradication of the infection [Bisno, 2001]:
- In people with group A streptococcal pharyngitis, one randomized trial found that those treated with phenoxymethylpenicillin for 7 days had a significantly greater treatment failure rate (30/96, 31%) compared with those receiving 10 days of phenoxymethylpenicillin (17/95, 18%). Compliance rates were 66–81% of patients [Schwartz et al, 1981].
- Erythromycin and clarithromycin should be reserved for use in people with penicillin allergy. Macrolides have a broader spectrum of activity than phenoxymethylpenicillin and are thus more likely to drive the emergence of bacterial resistance, increase the risk of developing Clostridium difficile, and are associated with more adverse effects [HPA and Association of Medical Microbiologists, 2010].
- A 5–day treatment course of erythromycin or clarithromycin is recommended [HPA and Association of Medical Microbiologists, 2010].
- A systematic review of short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children found that short courses of broad-spectrum antibiotics were as effective as 10–day courses of penicillin for sore throat symptom treatment [Altamimi et al, 2009].
- Amoxicillin and glandular fever:
- Amoxicillin and other broad-spectrum penicillins should not be used for the blind treatment of sore throat. Maculopapular rashes occur commonly with ampicillin and amoxicillin but are not usually related to true penicillin allergy. They almost always occur in people with infectious mononucleosis [ABPI Medicines Compendium, 2005; BNF 54, 2007].
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