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Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management)

Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management)
Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management)
OBJECTIVE: To determine the effect of clinical scores that predict streptococcal infection or rapid streptococcal antigen detection tests compared with delayed antibiotic prescribing.

DESIGN: Open adaptive pragmatic parallel group randomised controlled trial.

SETTING: Primary care in United Kingdom.

PATIENTS: Patients aged ?3 with acute sore throat.

INTERVENTION: An internet programme randomised patients to targeted antibiotic use according to: delayed antibiotics (the comparator group for analyses), clinical score, or antigen test used according to clinical score. During the trial a preliminary streptococcal score (score 1, n=1129) was replaced by a more consistent score (score 2, n=631; features: fever during previous 24 hours; purulence; attends rapidly (within three days after onset of symptoms); inflamed tonsils; no cough/coryza (acronym FeverPAIN).

OUTCOMES: Symptom severity reported by patients on a 7 point Likert scale (mean severity of sore throat/difficulty swallowing for days two to four after the consultation (primary outcome)), duration of symptoms, use of antibiotics.

RESULTS: For score 1 there were no significant differences between groups. For score 2, symptom severity was documented in 80% (168/207 (81%) in delayed antibiotics group; 168/211 (80%) in clinical score group; 166/213 (78%) in antigen test group). Reported severity of symptoms was lower in the clinical score group (-0.33, 95% confidence interval -0.64 to -0.02; P=0.04), equivalent to one in three rating sore throat a slight versus moderate problem, with a similar reduction for the antigen test group (-0.30, -0.61 to -0.00; P=0.05). Symptoms rated moderately bad or worse resolved significantly faster in the clinical score group (hazard ratio 1.30, 95% confidence interval 1.03 to 1.63) but not the antigen test group (1.11, 0.88 to 1.40). In the delayed antibiotics group, 75/164 (46%) used antibiotics. Use of antibiotics in the clinical score group (60/161) was 29% lower (adjusted risk ratio 0.71, 95% confidence interval 0.50 to 0.95; P=0.02) and in the antigen test group (58/164) was 27% lower (0.73, 0.52 to 0.98; P=0.03). There were no significant differences in complications or reconsultations.

CONCLUSION: Targeted use of antibiotics for acute sore throat with a clinical score improves reported symptoms and reduces antibiotic use. Antigen tests used according to a clinical score provide similar benefits but with no clear advantages over a clinical score alone.

TRIAL REGISTRATION: ISRCTN32027234.
0959-8138
1-10
Little, P.
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Hobbs, F.D.R.
ed141f5b-6bb8-49d5-ba3f-833ff8176556
Moore, M.
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Mant, D.
10e94981-cd2c-4e56-8a11-54d9fc107117
Williamson, I.
12381296-edbf-4ac5-969b-dcb559c22f27
McNulty, C.
c38d50cd-cf07-4482-88c8-75e33e205295
Cheng, Y.E.
91dc8157-56b9-40d4-a665-3899ddd8aa42
Leydon, G.
c5cdaff5-0fa1-4d38-b575-b97c2892ec40
McManus, R.
5daa415d-e0bc-471a-8b8e-e58a77d41ef0
Kelly, J.
b7094829-aeb1-4bc1-b64c-7b7c716f73b5
Barnett, J.
f10c0f99-e2f8-42e6-b52a-4987568453db
Glasziou, P.
c0469d98-7e80-450d-b354-e4bf74b209e4
Mullee, M.
fd3f91c3-5e95-4f56-8d73-260824eeb362
on behalf of the PRISM Investigators
Little, P.
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Hobbs, F.D.R.
ed141f5b-6bb8-49d5-ba3f-833ff8176556
Moore, M.
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Mant, D.
10e94981-cd2c-4e56-8a11-54d9fc107117
Williamson, I.
12381296-edbf-4ac5-969b-dcb559c22f27
McNulty, C.
c38d50cd-cf07-4482-88c8-75e33e205295
Cheng, Y.E.
91dc8157-56b9-40d4-a665-3899ddd8aa42
Leydon, G.
c5cdaff5-0fa1-4d38-b575-b97c2892ec40
McManus, R.
5daa415d-e0bc-471a-8b8e-e58a77d41ef0
Kelly, J.
b7094829-aeb1-4bc1-b64c-7b7c716f73b5
Barnett, J.
f10c0f99-e2f8-42e6-b52a-4987568453db
Glasziou, P.
c0469d98-7e80-450d-b354-e4bf74b209e4
Mullee, M.
fd3f91c3-5e95-4f56-8d73-260824eeb362

Little, P., Hobbs, F.D.R., Moore, M., Mant, D., Williamson, I., McNulty, C., Cheng, Y.E., Leydon, G., McManus, R., Kelly, J., Barnett, J., Glasziou, P. and Mullee, M. , on behalf of the PRISM Investigators (2013) Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). British Medical Journal, 347:f5806, 1-10. (doi:10.1136/bmj.f5806). (PMID:24114306)

Record type: Article

Abstract

OBJECTIVE: To determine the effect of clinical scores that predict streptococcal infection or rapid streptococcal antigen detection tests compared with delayed antibiotic prescribing.

DESIGN: Open adaptive pragmatic parallel group randomised controlled trial.

SETTING: Primary care in United Kingdom.

PATIENTS: Patients aged ?3 with acute sore throat.

INTERVENTION: An internet programme randomised patients to targeted antibiotic use according to: delayed antibiotics (the comparator group for analyses), clinical score, or antigen test used according to clinical score. During the trial a preliminary streptococcal score (score 1, n=1129) was replaced by a more consistent score (score 2, n=631; features: fever during previous 24 hours; purulence; attends rapidly (within three days after onset of symptoms); inflamed tonsils; no cough/coryza (acronym FeverPAIN).

OUTCOMES: Symptom severity reported by patients on a 7 point Likert scale (mean severity of sore throat/difficulty swallowing for days two to four after the consultation (primary outcome)), duration of symptoms, use of antibiotics.

RESULTS: For score 1 there were no significant differences between groups. For score 2, symptom severity was documented in 80% (168/207 (81%) in delayed antibiotics group; 168/211 (80%) in clinical score group; 166/213 (78%) in antigen test group). Reported severity of symptoms was lower in the clinical score group (-0.33, 95% confidence interval -0.64 to -0.02; P=0.04), equivalent to one in three rating sore throat a slight versus moderate problem, with a similar reduction for the antigen test group (-0.30, -0.61 to -0.00; P=0.05). Symptoms rated moderately bad or worse resolved significantly faster in the clinical score group (hazard ratio 1.30, 95% confidence interval 1.03 to 1.63) but not the antigen test group (1.11, 0.88 to 1.40). In the delayed antibiotics group, 75/164 (46%) used antibiotics. Use of antibiotics in the clinical score group (60/161) was 29% lower (adjusted risk ratio 0.71, 95% confidence interval 0.50 to 0.95; P=0.02) and in the antigen test group (58/164) was 27% lower (0.73, 0.52 to 0.98; P=0.03). There were no significant differences in complications or reconsultations.

CONCLUSION: Targeted use of antibiotics for acute sore throat with a clinical score improves reported symptoms and reduces antibiotic use. Antigen tests used according to a clinical score provide similar benefits but with no clear advantages over a clinical score alone.

TRIAL REGISTRATION: ISRCTN32027234.

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Published date: 10 October 2013
Organisations: Primary Care & Population Sciences

Identifiers

Local EPrints ID: 359217
URI: https://eprints.soton.ac.uk/id/eprint/359217
ISSN: 0959-8138
PURE UUID: 305aa92a-cc3a-4b41-8969-c49daf90a039
ORCID for M. Moore: ORCID iD orcid.org/0000-0002-5127-4509
ORCID for G. Leydon: ORCID iD orcid.org/0000-0001-5986-3300

Catalogue record

Date deposited: 23 Oct 2013 13:34
Last modified: 19 Jul 2019 00:55

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