Delayed antibiotics have similar benefits to those taken straight away, according to UK study

A delayed antibiotic strategy for the treatment of sore throat confers similar symptomatic benefits to immediate antibiotics, according to research from the University of Southampton and published online on 14 August 2017^[1]
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In a large cohort study of acute sore throat presenting in UK primary care, 2,876 participants were required to complete a symptom diary in order to provide detailed information regarding the rate of recovery of their symptoms. The researchers then used the diaries to assess whether a delayed prescription results in worse symptom outcomes.

Individuals who were not prescribed antibiotics reported poorer symptom control compared with those prescribed immediate antibiotics or a delayed antibiotic prescription. Those prescribed immediate antibiotics experienced both a reduction in symptom severity on day 2–4 and a reduction in the duration of moderately bad symptoms on 1 day with similar benefits observed in those receiving a delayed prescription.

“This is reassuring since we have already shown that using a ‘just in case’ prescription appears to reduce the risk of infective complications from sore throat and reduces exposure to antibiotics since many people do not need to use their prescription,” said Michael Moore, professor of primary care research at the University of Southampton and lead author of the two studies. 

“So using a ‘just in case’ prescription in practice has some benefits but the people using the strategy do not appear to be suffering more severe symptoms as a result,” he added.

In a second investigation looking at whether duration of treatment had any effect on the rate of recovery or the risk of a patient having to consult the doctor a second time, the researchers also found that a 10-day course of antibiotics is not associated with a greater benefit compared with 5- or 7-day antibiotic duration^[2]
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Within the same cohort the researchers found that, in comparison with a 5-day course, those prescribed a 10-day course appeared to have slightly worse symptomatic outcomes and, although the re-consultation rate was higher with shorter courses (15.2% for the 5-day group compared to 12.2% for the 10-day group), the difference did not reach statistical significance. It was also found that there was variation in the duration of antibiotic prescriptions, with the majority receiving 7 days, contrary to current guidelines.

“Longer courses are recommended to prevent relapse of symptoms,” explained Moore. “While we did show a small difference in the risk of relapse this did not reach statistical significance, and the effect was small.”

Commenting on the first study, Kieran Hand, consultant anti-infectives pharmacist at Southampton General Hospital, said that it provides valuable insight into the real-world medical management of adult patients presenting to their GP with acute sore throat.

“[It] provides reassurance to clinicians electing to prescribe a shorter antibiotic course length to relieve symptoms of sore throat,” he said. “Other useful information from the study is that complication rates were low and antibiotics other than phenoxymethylpenicillin were associated with a greater risk of re-consultation.

“A randomised controlled trial of different course lengths (including antibiotic resistance outcomes) is still required to definitively answer the question of which course length is optimal,” he added.

Helen Stokes-Lampard, chair of the Royal College of GPs, said that it is important that the results of the studies are taken on board, along with those of other emerging clinical studies, as guidelines are updated and developed in the best interests of our patients and public health as a whole.

“However, our advice to patients will remain the same,” she said. “Once a GP has recommended a course of antibiotics then patients should take the full course of antibiotics, as specified by the healthcare professional who prescribed them.”

The National Institute of Health and Care Excellence (NICE) has just come to the end of its consultation on new guidance for antimicrobial prescribing for sore throat.