NHG Guideline on Acute Sore Throat

The revised guideline on ‘Acute Sore Throat’ published by the Dutch College of General Practitioners (NHG) provides clear recommendations for the diagnostics and treatment of acute sore throat. The guideline is justifiably reticent in its recommendations for drug therapy, both as regards the choice of painkillers and as regards the decision to start antibiotics. Paracetamol is a good choice. Recommending NSAIDs with their sometimes serious side-effects and risks of interactions (especially among elderly patients with polypharmacy) for such relatively harmless disorders as a sore throat should be avoided as much as possible, and the guideline’s recommendation to discourage NSAID lozenges fits in with this view.

Although the risk of sepsis due to drug-induced agranulocytosis or leukopenia is low, it is nevertheless highly important, as this is a very serious side-effect. The same is true for a suspected epiglottitis.

The use of azitromycin is associated with an elevated risk of cardiovascular disorders and mortality, but the guideline only mentions this in the notes, not in the published tekst1. In addition, some of the literature cited is out of date, which means that  certain choices made in the guideline are insufficiently substantiated by the scientific literature.

  1. Dagnelie CF, et al. NHG-Standaard ’Acute keelpijn’. Huisarts Wet 2015; 58: 422-429.
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  3. Evans CE, et al. Sore throats in adults: who sees a doctor? Can Fam Physician 1982; 28: 453-458.
  4. Bisno AL, et al. Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Infectious Diseases Society of America. Clin Infect Dis 1997; 25: 574-583.
  5. Kumar S, et al. Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. BMJ 2003; 326: 138.
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  7. Shaikh N, et al. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr 2012; 160: 487-493.
  8. Little P, et al. Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study. Br J Gen Pract 2012; 62: e787-e794.
  9. Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam Physician 2004; 70: 1279-1287.
  10. Spinks A, et al. Antibiotics for sore throat. Cochrane Database Syst Rev 2013; 11: CD000023.
  11. Van de Lisdonk EH, et al (red.). Ziekten in de huisartspraktijk. Utrecht: Bunge, 1994.
  12. Sutton RN. Clinical aspects of infection with the Epstein-Barr virus. J R Coll Physicians Lond 1975; 9: 120-128.
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  14. Dunn N, et al. Use of antibiotics for sore throat and incidence of quinsy. Br J Gen Pract 2007; 57: 45-49.
  15. Little P, et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ 2013a; 347: f5806.
  16. Little P, et al. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis 2014; 14: 213-219.
  17. Hoogendoorn D. Acuut reuma en acute glomerulonefritis; huidige klinische incidentie en de sterfte in Nederland. Ned Tijdschr Geneeskd 1989; 133: 2334-2338.
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  19. De beoogde referentie was: Kwaliteitskoepel Medische Specialisten (2014). ZATT-richtlijn ( Ziekten Adenoid en Tonsillen in de Tweede lijn). http://www.kwaliteitskoepel.nl. Deze site is komen te vervallen en thans is alleen de richtlijn uit 2009 zichtbaar. Verschuur HP, et al. Ziekten Adenoid en Tonsillen in de Tweede lijn. NTvG 2009; 153: B295.
  20. Burton MJ, et al. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2014; 11: CD001802.
  21. Little P, et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ 2013a; 347: f5806.
  22. Llor C, et al. Impact on antibiotic prescription of rapid antigen detection testing in acute pharyngitis in adults: a randomised clinical trial. Br J Gen Pract 2011; 61: e244-e251.
  23. Worrall G, et al. Diagnosing streptococcal sore throat in adults: randomized controlled trial of in-office aids. Can Fam Physician 2007; 53: 666-671.

*The literature refers to the Dutch text