Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial

Efficacy of Corticosteroids for Sore Throat Management in Adults: A Systematic Review and Meta-Analysis of Randomized Trials

Sore throat (acute pharyngitis) is among the most common complaints among adults and is a reason for seeking healthcare globally. Antibiotics are widely used among patients with infectious sore throat. Previous research has indicated that corticosteroids could offer an alternative symptomatic treatment for sore throats. To estimate the corticosteroid efficacy as an additional therapy for sore throat adult patients, the literature search included PubMed, Medline, OVID, Cochrane CENTRAL, and Scopus for articles published until July 1st, 2024. The outcomes included the onset of pain relief (average time), complete resolution of pain (average time), absolute reduction of pain at 24 and 48 hours, requirement of antibiotics, and adverse effects related to treatment. Standardized mean difference (SMD) and risk difference were used to report numerical and dichotomous results. Five studies were included. Among the five included studies, corticosteroids showed significant effectiveness in resolving pain at 24 hours (average risk difference: 0.2200, 95% CI: 0.0500 to 0.3899, p = 0.0112) but with notable heterogeneity (I² = 82.4255%). At 48 hours, the benefit was not statistically significant (average risk difference: 0.4063, 95% CI: -0.1857 to 0.9984, p = 0.1786, I² = 98.9219%). Corticosteroids also decreased the average time to onset of pain relief (average SMD: -0.6590, 95% CI: -1.2857 to -0.0323, p = 0.0393, I² = 89.7914%), although with high heterogeneity. Other findings indicated a possible reduction in antibiotic use and fewer days missed from work. Adverse effects were minimal and occurred at similar rates in both corticosteroid and placebo arms. Corticosteroids can decrease pain intensity and duration in adults with acute sore throats. However, significant heterogeneity among studies and methodological limitations render the overall evidence inconclusive. While some studies noted reduced antibiotic use and lower symptom recurrence, high-quality RCTs are needed to address these limitations and provide more definitive guidelines for corticosteroid use in treating acute pharyngitis.

Revisiting dexamethasone use in the pediatric emergency department

PURPOSE OF REVIEW

Dexamethasone is an essential treatment for common pediatric inflammatory, airway, and respiratory conditions. We aim to provide up-to-date recommendations for treatment of anaphylaxis, croup, coronavirus disease, multisystem inflammatory syndrome in children, and asthma with dexamethasone for use in the pediatric emergency department.

RECENT FINDINGS

Literature largely continues to support the use of dexamethasone in most of the above conditions, however, recommendations for dosing and duration are evolving.

SUMMARY

The findings discussed in this review will enable pediatric emergency medicine providers to use dexamethasone effectively as treatment of common pediatric conditions and minimize the occurrence of side-effects caused by gratuitous corticosteroid use.

A pharynx-to-brain axis controls pharyngeal inflammation-induced anxiety

Anxiety is a remarkably common condition among patients with pharyngitis, but the relationship between these disorders has received little research attention, and the underlying neural mechanisms remain unknown. Here, we show that the densely innervated pharynx transmits signals induced by pharyngeal inflammation to glossopharyngeal and vagal sensory neurons of the nodose/jugular/petrosal (NJP) superganglia in mice. Specifically, the NJP superganglia project to norepinephrinergic neurons in the nucleus of the solitary tract (NTSNE). These NTSNE neurons project to the ventral bed nucleus of the stria terminalis (vBNST) that induces anxiety-like behaviors in a murine model of pharyngeal inflammation. Inhibiting this pharynx→NJP→NTSNE→vBNST circuit can alleviate anxiety-like behaviors associated with pharyngeal inflammation. This study thus defines a pharynx-to-brain axis that mechanistically links pharyngeal inflammation and emotional response.

Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation

Background

The place of tonsillectomy in the management of sore throat in adults remains uncertain.

Objectives

To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways.

Design

This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation.

Setting

The study took place at 27 NHS secondary care hospitals in Great Britain.

Participants

A total of 453 eligible participants with recurrent sore throats were recruited to the main trial.

Interventions

Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity.

Main outcome measures

The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms.

Results

There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it.

Limitations

The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial.

Conclusions

The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective.

Trial registration

This trial is registered as ISRCTN55284102.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.

Project rebuild the evidence base (REB): A method to interpret randomised clinical trials and their meta-analysis to present solid benefit-risk assessments to patients

Evidence-based medicine is the cornerstone of shared-decision making in healthcare today. The public deserves clear, transparent and trust-worthy information on drug efficacy. Yet today, many drugs are prescribed and used without solid evidence of efficacy. Clinical trials and randomised clinical trials (RCTs) are the best method to evaluate drug efficacy and side effects. In a shared medical decision-making approach, general practitioners need drug assessment based on patient-important outcomes. The aim of project rebuild the evidence base (REB) is to bridge the gap between the data needed in clinical practice and the data available from clinical research. The drugs will be assessed on clinical patient important outcomes and for a population. Using the Cochrane tools, we propose to analyse for each population and outcome: 1) a meta-analysis based on RCTs with a low risk of bias overall; 2) an evaluation of results of confirmatory RCTs; 3) a statistical analysis of heterrogeneity between RCTs and 4) an analysis of publication bias. Depending on the results of these analyses, the evidence will be categorized in 4 different levels: firm evidence, evidence (to be confirmed), signal or absence of evidence. Project REB proposes a method for reading and interpreting RCTs and their meta-analysis to produce quality data for general practitioners to focus on risk-benefit assessment in the interest of patients. If this data does not exist, it could enable clinical research to better its aim.

Kikyo-to for Acute Upper Respiratory Tract Infection-Associated Sore Throat Pain: A Multicenter Randomized Controlled Trial

Objectives: Kikyo-to (Kt), a herbal medicine composed of glycyrrhiza root (Chinese licorice) and Platycodon root extracts (Chinese bellflower), is commonly used in Japan for relief of throat symptoms related to acute upper respiratory tract infection (URTI). Its effectiveness on URTI-associated sore throat pain over 30 min is examined here in comparison with a placebo. Design: Randomized double-blinded multicenter trial. Settings/Location: Two local Japanese medical centers with primary care. Subjects: Patients aged 20-65 years with URTI-related sore throat. Interventions: Patients were randomized to receive either 2500 mg of Kt, or 2500 mg of placebo (lactose). Randomization was stratified by age (< 45 vs. ≥ 45 years) and baseline sore throat score according to visual analogue scale (VAS) (< 50 vs. ≥ 50). Outcome measures: Primary outcome was change to sore throat score according to VAS 30 min after administration of Kt. Perceived impact of the sore throat on daily life at 30 mins after administration was another outcome. Outcomes are analyzed in the intention-to-treat population. Results: Among 70 participants, (Kt group: 36; placebo group: 34), each group contained 34 patients for analysis (n = 68, total). Difference between the groups in the mean change of sore throat score according to VAS at 30 min was without statistical significance (Kt 15.3, placebo 17.2; p = 0.66). Patients reporting that their sore throat had a moderate or greater impact on daily life were also similar in proportion between the groups (Kt 61.8% vs. placebo 55.9%; p = 0.80). Side effects were not reported. Conclusions: Kt did not relieve acute URTI-associated sore throats significantly more than a placebo. (UMIN trial ID: UMIN000035591).

[Sore Throat - Guideline-based Diagnostics and Therapy]

Background

Sore throat is a common reason for consultation of family physicians. Acute sore throat (< 14 days) is usually triggered by infections of the pharynx. Less than 35 % of cases are caused by bacterial infections; nevertheless, antibiotics are prescribed far more often. Evidence-based guideline recommendations are available to reduce non-indicated administration of antibiotics in the treatment of sore throat.

Search Methods

Update of the clinical guideline "sore throat" of the German College of General Practitioners and Family Physicians (DEGAM) by means of a systematic search of the literature for international guidelines and systematic reviews.

Main Messages

After excluding red flags such as immunosuppression and severe systemic infections, acute sore throat is usually self-limiting with a mean duration of 7 days. Patients should be encouraged in self-management; ibuprofen and naproxen are recommended for symptomatic treatment. If antibiotics are considered, clinical scores (Centor, McIsaac, FeverPAIN) should be used to assess the risk of bacterial pharyngitis. At low risk (< 3 points), antibiotics are not indicated; if at least moderate (3 points), delayed prescription is an option; if high (> 3 points), antibiotics can be taken immediately. Even if scores suggestive a bacterial cause, the evidence suggests that antibiotic treatment only shortens the duration of symptoms modestly. Penicillin is the first choice (clarithromycin as an alternative). The antibiotic should be taken for 5-7 days.

Conclusions

In the absence of red flags, a regular use of symptomatic treatment will help to control discomfort. If administration of antibiotics is still considered a risk-adapted approach, using clinical scores is recommended.

Antibiotic prescribing and use of corticosteroids for the emergency department management of acute uncomplicated pharyngitis

BACKGROUND

Acute pharyngitis is common in the ambulatory setting. The Modified Centor score uses five criteria to predict Group A Streptococcus (GAS) infection and can be used to guide management.

OBJECTIVE

The objective of this study was to describe the emergency department (ED) management (throat cultures, antibiotics and corticosteroids) of acute, uncomplicated pharyngitis by Centor score.

METHODS

This was a retrospective chart review of adult (>17 years) patients with an ED discharge diagnosis of acute pharyngitis from January 2016 to December 2018.

RESULTS

Of 638 patients included, 286 (44.8%) had a Centor score of 0-1, 328 (51.4%) had a score of 2-3 and 24 (3.8%) had a score of ≥4. Of those with a Centor score of 0-1, 83 (29.0%) had a throat culture, 88 (30.8%) were prescribed antibiotics, 15 (5.2%) were positive for GAS and 74 (25.9%) received corticosteroids. Of those with a Centor score of 2-3, 156 (47.6%) had a throat culture, 220 (67.1%) were prescribed antibiotics, 44 (13.4%) were positive for GAS and 145 (44.2%) received corticosteroids. Of those with a Centor score ≥4, 14 (58.3%) had a throat culture, 18 (75.0%) were prescribed antibiotics, 7 (29.2%) were positive for GAS and 12 (50.0%) received corticosteroids.

CONCLUSIONS

A higher Centor score was associated with a higher risk of GAS infection, increased antibiotic prescribing and use of corticosteroids. Many patients with low Centor scores were prescribed antibiotics and had throat cultures. Further work is required to understand clinical decision-making for the management of acute pharyngitis.

Diagnostic accuracy of Fever-PAIN and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial

Background

Sore throat is a common and self-limiting condition. There remains ambiguity in stratifying patients to immediate, delayed, or no antibiotic prescriptions. The National Institute for Health and Care Excellence (NICE) recommends two clinical prediction rules (CPRs), FeverPAIN and Centor, to guide decision making.

Aim

To describe the diagnostic accuracy of CPRs in identifying streptococcal throat infections.

Design & setting

Adults presenting to UK primary care with sore throat, who did not require immediate antibiotics.

Method

As part of the Treatment Options without Antibiotics for Sore Throat (TOAST) trial, 565 participants, aged ≥18 years, were recruited on day of presentation to general practice. Physicians could opt to give delayed prescriptions. CPR scores were not part of the trial protocol but were calculated post hoc from baseline assessments. Diagnostic accuracy was calculated by comparing scores with throat swab cultures.

Results

It was found that 81/502 (16.1%) patients had group A, C, or G streptococcus cultured on throat swab. Overall diagnostic accuracy of both CPRs was poor: area under receiver operating characteristics (ROC) curve 0.62 for Centor; and 0.59 for FeverPAIN. Post-test probability of a positive or negative test was 27.3% (95% confidence interval [CI] = 6.0% to 61.0%) and 84.1% (95% CI = 80.6% to 87.2%) for FeverPAIN ≥4; versus 25.7% (95% CI = 16.2% to 37.2%) and 85.5% (95% CI = 81.8% to 88.7%) for Centor ≥3. Higher CPR scores were associated with increased delayed antibiotic prescriptions (χ² = 8.42, P = 0.004 for FeverPAIN ≥4; χ² = 32.0, P<0.001 for Centor ≥3).

Conclusion

In those who do not require immediate antibiotics in primary care, neither CPR provides a reliable way of diagnosing streptococcal throat infection. However, clinicians were more likely to give delayed prescriptions to those with higher scores.

Clinical Practice Guideline: Sore Throat

BACKGROUND

Sore throat is a common reason for consultation of primary care physicians, pediatricians, and ENT specialists. The updated German clinical practice guideline on sore throat provides evidence-based recommendations for treatment in the German healthcare system.

METHODS

Guideline revision by means of a systematic search of the literature for international guidelines and systematic reviews. All recommendations resulted from interdisciplinary cooperation and were agreed by formal consensus. The updated guideline applies to patients aged 3 years and over.

RESULTS

In the absence of red flags such as immunosuppression, severe comorbidity, or severe systemic infection, acute sore throat is predominantly self-limiting. The mean duration is 7 days. Chronic sore throat usually has noninfectious causes. Laboratory tests are not routinely necessary. Apart from non-pharmacological self-management, ibuprofen and naproxen are recommended for symptomatic treatment. Scores can be used to assess the risk of bacterial pharyngitis: one point each is assigned for tonsil lesions, palpable cervical lymph nodes, patient age, disease course, and elevated temperature. If the risk is low (<3 points), antibiotics are not indicated; if at least moderate (3 points), delayed prescribing is recommended; if high (>3 points), antibiotics can be taken immediately. Penicillin remains the first choice, with clarithromycin as an alternative for those who do not tolerate penicillin. The antibiotic should be taken for 5-7 days.

CONCLUSION

After the exclusion of red flags, antibiotic treatment is unnecessary in many cases of acute sore throat. If administration of antibiotics is still considered in spite of consultation on the usual course of tonsillopharyngitis and the low risk of complications, a risk-adapted approach using clinical scores is recommended.

[How to reduce the antibacterial load in the treatment of acute tonsillitis and pharyngitis? Possible tactics and practical approaches]

Acute tonsillopharyngitis is one of the most frequent reasons for visiting a doctor and prescribing inappropriate antibiotic therapy (ABT). There are several reasons for this - from the difficulties of etiological diagnosis and the development of relapses and possible severe complications to the personal attitude of doctors and patients to the choice of treatment. At the same time, the issue of antibiotic resistance and other aspects associated with the prescription of ABT is one of the most important problems of modern healthcare worldwide. The purpose of this review is to demonstrate the best practical approaches to the choice of treatment tactics for acute tonsillitis (AT) in the treatment of children and adults, with an emphasis on reducing the load of ABT. The review examines the indications and disadvantages of clinical and laboratory diagnosis of AT. There are no highly sensitive clinical and laboratory instruments that differentiate viral and bacterial AT. Exudativeis AT in children is not an underlying symptom of streptococcal etiology. Despite the limitations, the modified Centor/McIsaac score ≥3 (taking into account age and the presence of respiratory symptoms) should be used as an indication for ABT in conjunction with a rapid streptotest and subsequent bacteriological culture for S. pyogenes if the screening test is negative. Additional examinations (determination of leukocytosis, CRP and procalcitonin test) are not required for most patients. ABT should not be given to low-risk patients for the treatment and prevention of rheumatic fever and acute glomerulonephritis. Prevention of purulent complications (paratonsillitis and retropharyngeal abscess, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis) is not a specific indication for ABT in AT and is not required in most patients. The strategy of «delayed antibiotic prescriptions» with monitoring the patient's condition for 2-3 days is appropriate and highly effective in doubtful cases. The drugs of choice for treatment of AT are amoxicillin and oral forms of I and II generation cephalosporins. Macrolides are not indicated as first-line treatment for AT. The course of ABT for streptococcal AT is 10 days, which reduces the risk of recurrent episode. Topical drugs can be the only means of etiopathogenetic treatment with viral AT, or additional for bacterial AT. Their use not only relieves sore throat, but also shortens the duration of the disease, and also improves the patients prognosis. Benzalkonium chloride + tyrothricin + benzocaine (Dorithyrcin) may be a rational drug of choice for topical therapy due to the available clinical evidence. There is a significant reserve for reducing the load of ABT during AT. Further clinical trials are needed to assess the efficacy of short courses of ABT in the treatment of AT in high-income countries and provide a basis for strong recommendations for topical drug use. This can reduce the frequency of ABT prescribing and increase the level of interaction between specialists and patients.

Oral corticosteroids for post-infectious cough in adults: study protocol for a double-blind randomized placebo-controlled trial in Swiss family practices (OSPIC trial)

BACKGROUND

Cough is a common reason for patients to visit general practices. So-called post-infectious cough is defined as lasting 3 to 8 weeks after an upper respiratory tract infection. It can be disabling in daily activities, with substantial impact on physical and psychosocial health, leading to impaired quality of life and increased health care costs. Recommendations for the management of post-infectious cough in primary care are scarce and incoherent. A systematic review and meta-analysis of randomized clinical trials (RCT) assessing patient-relevant benefits and potential harms of available treatments identified six eligible RCTs assessing different treatment regimens (i.e. inhaled fluticasone propionate, inhaled budesonide, salbutamol plus ipratropium-bromide, montelukast, nociception-opioid-1-receptor agonist, codeine, gelatine). No RCT found clear patient-relevant benefits and most had an unclear or high risk of bias. Post-infectious cough is thought to be mediated by inflammatory processes that are also present in exacerbations of asthma or chronic obstructive pulmonary diseases for which there is strong evidence that oral corticosteroids provide patient-relevant benefit without relevant harm. We therefore plan to conduct the first RCT evaluating the effectiveness of oral corticosteroids for post-infectious cough.

METHODS

We are conducting a triple-blinded randomized-controlled and multicentred superiority trial in primary health care practices in Switzerland. We will include 204 adult patients who consult their general practitioner (GP) for a cough lasting 3 to 8 weeks following an upper respiratory tract infection. Participants will be randomly allocated to either the 5-day treatment with oral corticosteroids or placebo. The primary outcome is cough-related quality of life assessed by the Leicester Cough Questionnaire score 14 days after randomization. Secondary outcomes include cough-related quality of life at several time points, overall cessation of cough and adverse events.

DISCUSSION

This RCT will provide evidence on whether oral corticosteroids are beneficial and safe in patients with post-infectious cough. Results can have a substantial impact on the well-being and management of these patients in Switzerland and beyond. An evidence-based treatment for this condition may reduce re-consultations with GPs and spending for antitussive drugs, thus possibly having an impact on health care spending.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04232449 . Prospectively registered on 18 January 2020.

Corticosteroids as standalone or add-on treatment for sore throat

BACKGROUND

Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract. This review is an update to our review published in 2012.

OBJECTIVES

To assess the clinical benefit and safety of corticosteroids in reducing the symptoms of sore throat in adults and children.

SEARCH METHODS

We searched CENTRAL (Issue 4, 2019), MEDLINE (1966 to 14 May 2019), Embase (1974 to 14 May 2019), the Database of Abstracts of Reviews of Effects (DARE, 2002 to 2015), and the NHS Economic Evaluation Database (inception to 2015). We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared steroids to either placebo or standard care in adults and children (aged over three years) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis (glandular fever), sore throat following tonsillectomy or intubation, or peritonsillar abscess.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included one new RCT in this update, for a total of nine trials involving 1319 participants (369 children and 950 adults). In eight trials, participants in both corticosteroid and placebo groups received antibiotics; one trial offered delayed prescription of antibiotics based on clinical assessment. Only two trials reported funding sources (government and a university foundation). In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by 2.40 times (risk ratio (RR) 2.4, 95% confidence interval (CI) 1.29 to 4.47; P = 0.006; I² = 67%; high-certainty evidence) and at 48 hours by 1.5 times (RR 1.50, 95% CI 1.27 to 1.76; P < 0.001; I² = 0%; high-certainty evidence). Five people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 11.6 hours, respectively, although significant heterogeneity was present (moderate-certainty evidence). At 24 hours, pain (assessed by visual analogue scales) was reduced by an additional 10.6% by corticosteroids (moderate-certainty evidence). No differences were reported in recurrence/relapse rates, days missed from work or school, or adverse events for participants taking corticosteroids compared to placebo. However, the reporting of adverse events was poor, and only two trials included children or reported days missed from work or school. The included studies were assessed as moderate quality evidence, but the small number of included studies has the potential to increase the uncertainty, particularly in terms of applying these results to children.

AUTHORS' CONCLUSIONS

Oral or intramuscular corticosteroids, in addition to antibiotics, moderately increased the likelihood of both resolution and improvement of pain in participants with sore throat. Given the limited benefit, further research into the harms and benefits of short courses of steroids is needed to permit informed decision-making.

Kikyo-to vs. Placebo on Sore Throat Associated with Acute Upper Respiratory Tract Infection: A Randomized Controlled Trial

Objective Kikyo-to (KKT) is a fixed combination of glycyrrhiza root and platycodon root extracts. It is an herbal medicine traditionally used in Japan for relieving sore throat associated with acute upper respiratory tract infection (URTI). No controlled studies have yet demonstrated its effect, however. We investigated the efficacy of KKT on sore throat associated with acute URTI. Methods Patients with sore throat who were diagnosed with URTI at the General Medicine Department Office, Akashi Medical Center Hospital, between December 2017 and May 2018 were enrolled. Participants were randomly assigned to two groups at a 1:1 ratio, with stratification by age and sore throat score on a Visual Analogue Scale (VAS), to receive 2.5 g of either KKT or a placebo. Participants and investigators were blinded to group allocation. The primary outcome was the change in sore throat score on VAS 10 minutes after KKT administration. Secondary outcomes were the impact of the sore throat on daily life (none, mild, moderate, and severe) at 10 minutes after administration. Results Thirty-five participants were assigned to each group (n=70, total). The difference in the mean change of sore throat score according to VAS within 10 minutes between the two groups was not statistically significant (KKT 14.40 vs. placebo 17.00; p=0.39). The proportion of patients with a moderate or greater impact of their sore throat on their daily life was also not significantly different between the groups (KKT 22.9% vs. placebo 40.0%; p=0.20). Patients reported no side effects. Conclusion KKT did not significantly relieve sore throat associated with acute URTI compared with placebo.

Ectoine lozenges in the treatment of acute viral pharyngitis: a prospective, active-controlled clinical study

PURPOSE

Acute pharyngitis is an uncomfortable disorder mostly caused by viruses and for which antibiotics are unwarranted. This study compared lozenges containing ectoine, a natural extremolyte, with hyaluronic acid lozenges and hypertonic saline gargle for symptomatic treatment of acute viral pharyngitis.

METHODS

This prospective, controlled clinical study, recruited 90 patients with moderate-to-severe pharyngitis symptoms who chose to use either ectoine (n = 35), hyaluronic acid (n = 35), or saline gargle (n = 20). Patients applied their 7-day treatment from the inclusion visit (V1) until the end-of-study visit (V2). Patients' pharyngitis symptoms, general health, general treatment effectiveness and tolerability, and patient compliance were assessed by investigators and patients.

RESULTS

The sum score for three primary symptoms (pain on swallowing, urge to cough, and hoarseness) decreased by 79.5% (ectoine), 72.2% (hyaluronic acid), and 44.8% (saline gargle). Both lozenges were significantly superior to saline gargle (P < 0.05). Regarding general health improvement, ectoine was significantly superior to saline gargle (72.5% vs. 45.2%, P < 0.05), but hyaluronic acid (63.3%) was not. At V2, 65.7% of patients receiving ectoine reported "very good" general health vs. 48.6% of those receiving hyaluronic acid and 20.0% using saline gargle. Ectoine was significantly superior (P < 0.05) to both hyaluronic acid and saline gargle in terms of tolerability and patient compliance. No patients taking ectoine reported unpleasant sensations while applying their treatment, whereas almost half of patients using hyaluronic acid lozenges and saline gargle did.

CONCLUSION

Treatment with ectoine lozenges significantly relieves moderate-to-severe symptoms of acute viral pharyngitis and is more effective and tolerable than treatments with hyaluronic acid lozenges and hypertonic saline gargle.

Economic analysis of oral dexamethasone for symptom relief of sore throat: the UK TOAST study

OBJECTIVES

To undertake an economic analysis assessing the cost-effectiveness of a single dose of oral dexamethasone compared with placebo for the relief of sore throat.

DESIGN

A UK-based, multicentre, two arm, individually randomised, double blind trial.

SETTING AND POPULATION

Adults (≥18 years) with acute sore throat and painful swallowing judged to be infective in origin, recruited and randomised in primary care.

INTERVENTION

a single dose of 10 mg oral dexamethasone compared with placebo given at primary care visit.

MAIN OUTCOME

Incremental cost-effectiveness ratios (ICERs), cost per quality-adjusted symptom resolution using the EuroQol-five dimensions-five levels instrument, were estimated as part of a cost-utility analysis performed on an intention-to-treat cohort adopting a health payers perspective.

RESULTS

Differences in health-related quality of life (HRQoL) over 7 days from baseline and at 24 hours in the dexamethasone compared with the placebo group (2.9% and 2.5% higher, respectively) were observed. After controlling for the baseline HRQoL imbalances, the economic impact of the intervention was not statistically significant: the quality-adjusted life year difference was -0.00005 (95% CI -0.0002 to 0.00011) equivalent to a loss in HRQoL of a half hour in the dexamethasone group. The average cost per patient associated in the dexamethasone and placebo groups in the basecase analysis was £73 and £69, respectively. In the basecase probabilistic analysis, the mean ICER was -£6440 (95% CI -£132 151 to £126 335) and the median ICER was -£304 (IQR-£5816 to £3877); suggesting considerable uncertainty.

CONCLUSIONS AND RELEVANCE

The economic burden associated with sore throat is substantial and was estimated at £2.35 billion to the healthcare services payer based on reported resource use and 2015 UK unit costs. There is considerable uncertainty regarding the cost-effectiveness of a single dose of oral dexamethasone as a treatment strategy and therefore insufficient evidence to support its use in clinical practice.

TRIAL REGISTRATION NUMBER

ISRCTN17435450; Post-results.

Explaining variation in antibiotic prescribing between general practices in the UK

Objectives

Primary care practices in England differ in antibiotic prescribing rates, and, anecdotally, prescribers justify high prescribing rates based on their individual case mix. The aim of this paper was to explore to what extent factors such as patient comorbidities explain this variation in antibiotic prescribing.

Methods

Primary care consultation and prescribing data recorded in The Health Improvement Network (THIN) database in 2013 were used. Boosted regression trees (BRTs) and negative binomial regression (NBR) models were used to evaluate associations between predictors and antibiotic prescribing rates. The following variables were considered as potential predictors: various infection-related consultation rates, proportions of patients with comorbidities, proportion of patients with inhaled/systemic corticosteroids or immunosuppressive drugs, and demographic traits.

Results

The median antibiotic prescribing rate was 65.6 (IQR 57.4-74.0) per 100 registered patients among 348 English practices. In the BRT model, consultation rates had the largest total relative influence on antibiotic prescribing rate (53.5%), followed by steroid and immunosuppressive drugs (31.6%) and comorbidities (12.2%). Only 21% of the deviance could be explained by an NBR model considering only comorbidities and age and gender, whereas 57% of the deviance could be explained by the model considering all variables.

Conclusions

The majority of practice-level variation in antibiotic prescribing cannot be explained by variation in prevalence of comorbidities. Factors such as high consultation rates for respiratory tract infections and high prescribing rates for corticosteroids could explain much of the variation, and as such may be considered in determining a practice's potential to reduce prescribing.

Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials

Objective To estimate the benefits and harms of using corticosteroids as an adjunct treatment for sore throat.Design Systematic review and meta-analysis of randomised control trials.Data sources Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), trial registries up to May 2017, reference lists of eligible trials, related reviews.Study selection Randomised controlled trials of the addition of corticosteroids to standard clinical care for patients aged 5 or older in emergency department and primary care settings with clinical signs of acute tonsillitis, pharyngitis, or the clinical syndrome of sore throat. Trials were included irrespective of language or publication status.Review methods Reviewers identified studies, extracted data, and assessed the quality of the evidence, independently and in duplicate. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including the selection of outcomes important to patients. Random effects model was used for meta-analyses. Quality of evidence was assessed with the GRADE approach.Results 10 eligible trials enrolled 1426 individuals. Patients who received single low dose corticosteroids (the most common intervention was oral dexamethasone with a maximum dose of 10 mg) were twice as likely to experience pain relief after 24 hours (relative risk 2.2, 95% confidence interval 1.2 to 4.3; risk difference 12.4%; moderate quality evidence) and 1.5 times more likely to have no pain at 48 hours (1.5, 1.3 to 1.8; risk difference 18.3%; high quality). The mean time to onset of pain relief in patients treated with corticosteroids was 4.8 hours earlier (95% confidence interval -1.9 to -7.8; moderate quality) and the mean time to complete resolution of pain was 11.1 hours earlier (-0.4 to -21.8; low quality) than in those treated with placebo. The absolute pain reduction at 24 hours (visual analogue scale 0-10) was greater in patients treated with corticosteroids (mean difference 1.3, 95% confidence interval 0.7 to 1.9; moderate quality). Nine of the 10 trials sought information regarding adverse events. Six studies reported no adverse effects, and three studies reported few adverse events, which were mostly complications related to disease, with a similar incidence in both groups.Conclusion Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects. Included trials did not assess the potential risks of larger cumulative doses in patients with recurrent episodes of acute sore throat.Systematic review registration PROSPERO CRD42017067808.