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

Paul Little, F. D. Richard Hobbs, Michael Moore, David Mant, Ian Williamson, Cliodna McNulty, Ying Edith Cheng, Geraldine Leydon, Richard McManus, Joanne Kelly, Jane Barnett, Paul Glasziou, Mark Mullee

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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.

Original languageEnglish
Article numberf5806
JournalBritish Medical Journal
Volume347
Issue number7930
DOIs
Publication statusPublished - 26 Oct 2013

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Pharyngitis
Primary Health Care
Randomized Controlled Trials
Anti-Bacterial Agents
Antigens
Confidence Intervals
Streptococcal Infections
Palatine Tonsil
Deglutition
Cough
Internet
Fever
Referral and Consultation
Odds Ratio

Cite this

Little, Paul ; Richard Hobbs, F. D. ; Moore, Michael ; Mant, David ; Williamson, Ian ; McNulty, Cliodna ; Cheng, Ying Edith ; Leydon, Geraldine ; McManus, Richard ; Kelly, Joanne ; Barnett, Jane ; Glasziou, Paul ; Mullee, Mark. / Clinical score and rapid antigen detection test to guide antibiotic use for sore throats : Randomised controlled trial of PRISM (primary care streptococcal management). In: British Medical Journal. 2013 ; Vol. 347, No. 7930.
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title = "Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: Randomised controlled trial of PRISM (primary care streptococcal management)",
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.",
author = "Paul Little and {Richard Hobbs}, {F. D.} and Michael Moore and David Mant and Ian Williamson and Cliodna McNulty and Cheng, {Ying Edith} and Geraldine Leydon and Richard McManus and Joanne Kelly and Jane Barnett and Paul Glasziou and Mark Mullee",
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Little, P, Richard Hobbs, FD, Moore, M, Mant, D, Williamson, I, McNulty, C, Cheng, YE, Leydon, G, McManus, R, Kelly, J, Barnett, J, Glasziou, P & Mullee, M 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, vol. 347, no. 7930, f5806. https://doi.org/10.1136/bmj.f5806

Clinical score and rapid antigen detection test to guide antibiotic use for sore throats : Randomised controlled trial of PRISM (primary care streptococcal management). / Little, Paul; Richard Hobbs, F. D.; Moore, Michael; Mant, David; Williamson, Ian; McNulty, Cliodna; Cheng, Ying Edith; Leydon, Geraldine; McManus, Richard; Kelly, Joanne; Barnett, Jane; Glasziou, Paul; Mullee, Mark.

In: British Medical Journal, Vol. 347, No. 7930, f5806, 26.10.2013.

Research output: Contribution to journalArticleResearchpeer-review

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T1 - Clinical score and rapid antigen detection test to guide antibiotic use for sore throats

T2 - Randomised controlled trial of PRISM (primary care streptococcal management)

AU - Little, Paul

AU - Richard Hobbs, F. D.

AU - Moore, Michael

AU - Mant, David

AU - Williamson, Ian

AU - McNulty, Cliodna

AU - Cheng, Ying Edith

AU - Leydon, Geraldine

AU - McManus, Richard

AU - Kelly, Joanne

AU - Barnett, Jane

AU - Glasziou, Paul

AU - Mullee, Mark

PY - 2013/10/26

Y1 - 2013/10/26

N2 - 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.

AB - 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.

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