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Test for sore throat cuts antibiotic use by nearly a third

PRISM study

A clinical scoring test developed by NIHR-funded researchers has cut the use of antibiotics prescribed for sore throats by nearly a third. Used daily in primary care, the FeverPAIN score is a cost-effective approach to manage patients’ symptoms and reduce antibiotic use.

Published: 26 March 2024

When to treat with antibiotics?

Sore throats account for at least 1 in 4 GP appointments related to respiratory tract infections. Many cases will resolve without treatment but for patients with bacterial infections, antibiotics can help them recover a little more quickly.

Knowing which patients will benefit from antibiotics can be difficult for GPs. Without evidence, up to 60% of patients may receive them unnecessarily. GPs can use two approaches to detect bacterial throat infections: rapid antigen detection tests, which detect Group A Streptococcus bacteria, and clinical scoring methods, such as the Centor score or the FeverPAIN score

The NHS is committed to finding ways of targeting antibiotic treatment, reducing their use and minimising antibiotic resistance. In support of this, the NIHR awarded researchers at the University of Southampton £820,000 to undertake a series of studies as part of the overall PRImary care Streptococcal Management project (PRISM). 

As part of this award, the researchers developed the FeverPAIN score (published in BMJ Open). It uses a five-item score to assess whether a bacterial infection is likely and requires antibiotics.

Supporting evidence-based prescribing

Led by Paul Little, Professor of Primary Care Research, the PRISM team then trialled the FeverPAIN score. They found that it reduced antibiotic use by almost 30% compared with issuing a delayed prescription. Although patients in the FeverPAIN score group used fewer antibiotics, they also experienced greater improvement in both the severity and duration of their symptoms.

Where rapid tests were used alongside the FeverPAIN score to detect bacteria, they didn’t alter GPs’ decisions about prescribing antibiotics any more than using the FeverPAIN score alone. Professor Little’s team therefore concluded that the additional time and cost of using these tests did not benefit patients’ care. Their results are published in the BMJ

“PRISM’s findings show that using this clinical score test can target antibiotics more effectively and help persuade patients antibiotics are not needed.” - Professor Paul Little, lead researcher for the PRISM trial

Changing practice and cutting costs

PRISM’s work had wide-reaching impact across primary care, with the 2018 NICE guideline listing FeverPAIN as a recommended approach for bacterial throat infection diagnosis. PRISM also informed NICE’s online Clinical Knowledge Summary on sore throats, giving primary care practitioners current evidence for best practice. 

The World Health Organization’s 2020 review of the use of essential in vitro diagnostics also cited PRISM’s evidence on clinical scores being a cost-effective approach to diagnosing Group A Streptococcus.

Following their study, the researchers created a FeverPAIN app that is widely used within GP consultation systems. To further support GPs’ antibiotic prescribing, Professor Little then worked with the Royal College of General Practitioners to co-develop the TARGET online toolkit for respiratory tract infections

TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) incorporates both FeverPAIN and training on delayed prescribing. In 2019, the UK’s 5-year antibiotic resistance action plan recognised TARGET as the most accessed part of the Royal College of General Practitioners’ website.

The study was funded by the NIHR Health Technology Assessment (HTA) Programme.

More information about the study is available on the NIHR’s Funding & Awards website.

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