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.
  
  
  METHODS
  Open adaptive pragmatic parallel group randomised controlled trial.
  
  
  METHODS
  Primary care in United Kingdom.
  
  
  METHODS
  Patients aged ≥ 3 with acute sore throat.
  
  
  METHODS
  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).
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  ISRCTN32027234.
authors.affiliation: University of Southampton Medical School, Aldermoore Health Centre, Southampton SO16 5ST, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Little
authors.forename: F D Richard
authors.initials: FD
authors.lastname: Hobbs
authors.forename: Michael
authors.initials: M
authors.lastname: Moore
authors.forename: David
authors.initials: D
authors.lastname: Mant
authors.forename: Ian
authors.initials: I
authors.lastname: Williamson
authors.forename: Cliodna
authors.initials: C
authors.lastname: McNulty
authors.forename: Ying Edith
authors.initials: YE
authors.lastname: Cheng
authors.forename: Geraldine
authors.initials: G
authors.lastname: Leydon
authors.forename: Richard
authors.initials: R
authors.lastname: McManus
authors.forename: Joanne
authors.initials: J
authors.lastname: Kelly
authors.forename: Jane
authors.initials: J
authors.lastname: Barnett
authors.forename: Paul
authors.initials: P
authors.lastname: Glasziou
authors.forename: Mark
authors.initials: M
authors.lastname: Mullee
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D000942:Antigens, Bacterial / Q000276:immunology / Q000302:isolation & purification*; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D007159:Immunologic Tests / Q000379:methods*; D008297:Male; D010612:Pharyngitis / Q000188:drug therapy* / Q000276:immunology / Q000382:microbiology; D012680:Sensitivity and Specificity; D013290:Streptococcal Infections / Q000188:drug therapy* / Q000276:immunology / Q000382:microbiology; D013297:Streptococcus pyogenes / Q000276:immunology / Q000302:isolation & purification*; D011795:Surveys and Questionnaires; D006113:United Kingdom
chemical_list: D000900:Anti-Bacterial Agents; D000942:Antigens, Bacterial