29 July 2019

Why more docs should be saying: ‘Say ahh’

General Practice Research

Unnecessary prescribing of antibiotics for sore throats might be reduced if GPs apply and document a simple set of criteria, according to a South Australian study.

Dr Chirag Patel, from Flinders University, analysed 1554 records from two rural general practices and found that more than 80% of patients who presented with pharyngitis, tonsillitis or tonsillopharyngitis were prescribed antibiotics. 

This is despite the fact that only 5 to 17% of sore throats in adults, and up to 30% in children, are caused by the group A -haemolytic streptococcus (GABHS) that the antibiotics target, and that the drugs only reduce duration of symptoms by up to a day.

In his study, published in the Australian Journal of General Practice, Dr Patel found that documentation of evidence of the McIsaac Score or Modified Centor Criteria (MCC) was associated with lower prescribing rates.

The MCC is a simple test of five factors: age, exudate or swelling on tonsils, tender or swollen lymph nodes, temperature greater than 38°C and cough. Even a maximum score of 5 means the likelihood of GABHS is just above 50%.

The automatic prescription of antibiotics is a hangover from the era when acute rheumatic fever was a common result of strep A infections, Dr Patel told The Medical Republic – a risk that still pertains in remote Aboriginal communities and leads to rheumatic heart disease.  Dr Patel, a consultant primary care physician, said even though the advice in Western urban settings was not to give antibiotics, it was still extremely common.

“Even if you go to the emergency department they’ll prescribe antibiotics because it’s just what they do and the patient feels satisfied,” he said.

While he found a statistically lower rate of prescribing among doctors who documented any of the MCC criteria – 77% compared with 85.5% – even those patients with low scores were often prescribed antibiotics.

Dr Patel said the data could not show whether the act of documentation had an inhibiting effect on prescribing or whether the more scrupulous doctors both documented more and prescribed less.

“That’s the hardest part – we couldn’t work that out in the study,” he said.

“It could have been both. The thinking is that if someone’s documenting correctly they’re more likely to make better prescribing decisions because they’re practising better medicine.

“The idea is to get the information across that documentation is important and there is a tool you can use to reduce antibiotic prescribing.”

He said explanations to patients was also key to reducing overprescribing in an era of antibiotic resistance.

“They always come in for antibiotics, and I tell them the easiest thing for me would be to print a script and give it to you. Instead, I spend time explaining why an antibiotic is not necessary.

“The majority are satisfied by the explanation. There’ll be one or two who’ll book in with another doctor the next day, but you can’t help that. You always tell them, come back if things don’t get better by such and such a day. They can get upset, but given a clear explanation hopefully they’ll feel satisfied.”

He said even in populations at high risk of ARF and RHD, environmental factors probably played at least as great a role as genetics, and Aboriginal patients in good living conditions might not need antibiotics either.