National Institute for Health and Care Excellence APG: sore throat (acute) - draft for consultation Sore throat (acute): antimicrobial prescribing guideline Evidence review July 2017 Draft for Consultation DRAFT FOR CONSULTATION Contents Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © National Institute for Health and Care Excellence, 2017. All rights reserved. ISBN: DRAFT FOR CONSULTATION Contents Contents Contents .............................................................................................................................. 4 1 Context .......................................................................................................................... 6 1.1 Background ........................................................................................................... 6 1.2 Managing self-limiting infections ............................................................................ 6 1.2.1 Self-care .................................................................................................... 7 1.2.2 No antibiotic prescribing strategies ............................................................. 7 1.2.3 Antibiotic prescribing strategies .................................................................. 8 1.3 Safety netting advice ............................................................................................. 8 1.4 Symptoms and signs of a more serious illness or condition (red flags) .................. 9 2 Evidence selection ..................................................................................................... 10 2.1 Literature search ................................................................................................. 10 2.2 Summary of included studies............................................................................... 10 3 Clinical effectiveness ................................................................................................. 16 3.1 Non-pharmacological interventions ..................................................................... 16 3.2 Non-antimicrobial pharmacological interventions ................................................. 16 3.2.1 Oral analgesia in adults ............................................................................ 16 3.2.2 Medicated lozenges in adults ................................................................... 17 3.2.3 Benzocaine lozenges ............................................................................... 17 3.2.4 Hexylresorcinol lozenges ......................................................................... 17 3.2.5 Flurbiprofen lozenges............................................................................... 17 3.2.6 Throat sprays ........................................................................................... 18 3.2.7 Corticosteroids ......................................................................................... 18 3.3 Antimicrobials ...................................................................................................... 19 3.3.1 Delayed antibiotics ................................................................................... 19 3.3.2 Antibiotics compared with placebo ........................................................... 20 3.3.3 Identifying people more likely to have a bacterial infection ....................... 20 3.3.4 Antibiotics compared with other antibiotics ............................................... 21 3.3.5 Frequency of antibiotic dosing .................................................................. 22 3.3.6 Antibiotic course length ............................................................................ 23 4 Safety and tolerability ................................................................................................ 24 4.1 Non-pharmacological interventions ..................................................................... 24 4.2 Non-antimicrobial pharmacological interventions ................................................. 24 4.2.1 Oral analgesia .......................................................................................... 24 4.2.2 Medicated lozenges ................................................................................. 24 4.2.3 Throat sprays ........................................................................................... 24 4.2.4 Corticosteroids ......................................................................................... 25 4.3 Antimicrobials ...................................................................................................... 25 4.3.1 Delayed antibiotics ................................................................................... 25 4.3.2 Antibiotics versus placebo ........................................................................ 26 4 DRAFT FOR CONSULTATION Contents 4.3.3 Antibiotics versus another antibiotic ......................................................... 26 5 Resistance .................................................................................................................. 27 6 Other considerations ................................................................................................. 28 6.1 Resource impact ................................................................................................. 28 6.2 Medicines adherence .......................................................................................... 28 7 Terms used in the guideline ...................................................................................... 29 Centor criteria ...................................................................................................... 29 Sore Throat Pain Intensity Scale (STPIS) ............................................................ 29 Sum of Pain Intensity Difference (SPID) .............................................................. 29 Tonsillo- Pharyngitis Assessment (TPA) .............................................................. 29 Total pain relief (TOTPAR) .................................................................................. 29 Throat Pain Scale ................................................................................................ 29 Appendices ........................................................................................................................ 30 Appendix A: Review protocol ..................................................................................... 30 Appendix B: Literature search strategy ..................................................................... 37 Appendix C: Study flow diagram ................................................................................ 43 Appendix D: Included studies ..................................................................................... 44 Appendix E: Quality assessment of included studies .............................................. 47 E.1 Oral analgesia ............................................................................................................. 47 E.2 Lozenges ..................................................................................................................... 49 E.3 Throat spray ................................................................................................................ 51 E.4 Corticosteroids ........................................................................................................... 52 E.5 Antimicrobials ............................................................................................................ 53 E.6 Clinical scoring systems and rapid antigen testing ................................................. 56 Appendix F: GRADE profiles ...................................................................................... 58 F.1 Oral analgesia ............................................................................................................. 58 F.2 Lozenges ..................................................................................................................... 63 F.3 Throat spray ...............................................................................................................