Corticosteroids for pain relief in sore throat: systematic review and meta-analysis

Evidence reversals in primary care research: a study of randomized controlled trials

BACKGROUND

Evidence-Based Medicine is built on the premise that clinicians can be more confident when their decisions are grounded in high-quality evidence. Furthermore, evidence from studies involving patient-oriented outcomes is preferred when making decisions about tests or treatments. Ideally, the findings of relevant and valid trials should be stable over time, that is, unlikely to be reversed in subsequent research.

OBJECTIVE

To evaluate the stability of evidence from trials relevant to primary healthcare and to identify study characteristics associated with their reversal.

METHODS

We studied synopses of randomized controlled trials (RCTs) published from 2002 to 2005 as "Daily POEMs" (Patient Oriented Evidence that Matters). The initial evidence (E1) from these POEMs (2002-2005) was compared with the updated evidence (E2) on that same topic in a summary resource (DynaMed 2019). Two physician-raters independently categorized each POEM-RCT as (i) reversed when E1 ≠ E2, or as (ii) not reversed, when E1 = E2. For all "Evidence Reversals" (E1 ≠ E2), we assessed the direction of change in the evidence.

RESULTS

We evaluated 408 POEMs on RCTs. Of those, 35 (9%; 95% confidence interval [6-12]) were identified as reversed, 359 (88%) were identified as not reversed, and 14 (3%) were indeterminate. On average, this represents about 2 evidence reversals per annum for POEMs about RCTs.

CONCLUSIONS

Over 12-17 years, 9% of RCTs summarized as POEMs are reversed. Information alerting services that apply strict criteria for relevance and validity of clinical information are likely to identify RCTs whose findings are stable over time.

Oral prednisolone for acute lower respiratory tract infection in clinically unrecognised asthma: an exploratory analysis of the Oral Steroids for Acute Cough (OSAC) randomised controlled trial

Background

Acute lower respiratory tract infection (ALRTI) is often treated in primary care with antibiotics. The recent Oral Steroids for Acute Cough (OSAC) randomised controlled trial (RCT) showed corticosteroids were not an effective alternative in adults without a diagnosis of asthma with ALRTI.

Aim

To investigate if corticosteroids are beneficial for ALRTI in patients with unrecognised asthma.

Design & setting

An exploratory analysis was undertaken of the primary care OSAC trial.

Method

A subgroup analysis was performed in patients who responded ‘yes’ to the following International Primary Care Airways Group (IPCAG) question: did you have wheeze and/or at least two of nocturnal cough or chest tightness or dyspnoea in the past year. Sensitivity analyses were carried out on those who answered ‘yes’ to wheeze and at least two of the nocturnal symptoms. The primary outcomes were as follows: duration of cough (0–28 days, minimum clinically important difference [MCID] of 3.79 days) and mean symptom severity score (range 0–6; MCID 1.66 units).

Results

In total, 40 (10%) patients were included in the main analysis: mean age 49 years (standard deviation [SD] = 17.9), 52% male. Median cough duration was 3 days in both prednisolone (interquartile range [IQR] = 2–6 days) and placebo (IQR = 1–6 days) groups (adjusted hazard ratio [HR] = 1.10; 95% confidence interval [CI] = 0.47 to 2.54; P = 0.83), equating to 0.24 days longer in the prednisolone group (95% CI = 1.23 days shorter to 2.88 days longer). Mean symptom severity difference was –0.14 (95% CI = –0.78 to 0.49; P=0.65) comparing prednisolone with placebo. Similar findings were found in the sensitivity analysis.

Conclusion

No evidence was found to support the use of corticosteroids for ALRTI in patients with clinically unrecognised asthma. Clinicians should not use the IPCAG questions to target oral corticosteroid treatment in patients with ALRTI.

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.

In Ear Surgeries Intravenous Dexamethasone Preoperatively Decreases Post Operative Sore Throat After Endotracheal Intubation in Adult Patients: A Prospective Randomized Control Study

Sore throat is commonly seen after general anaesthesia with endotracheal intubation. It is distressing for the patient as it delays return to work, increases morbidity and bad memories of the surgical period with disturbances in sleep. This double-blinded prospective randomized study was done to know the efficacy of intravenous dexamethasone in decreasing the incidence of postoperative sore throat at 1, 6 and 24 h after tracheal extubation. 60 patients aged 18-50 years scheduled for ear surgeries under general anesthesia with endotracheal intubation, were randomly allocated into two groups A and B. The patients received either intravenous 0.2 mg/kg diluted till 4 ml dexamethasone (group A, n = 30) or 4 ml normal saline (group B, n = 30) prior to induction. Endotracheal intubation was done to secure the airway. Follow up for the incidence of sore throat was done at 1, 6 and 24 h post-extubation. At 1 h, 6 h and 24 h after extubating the patient, the incidence of sore throat in the control group was significantly less in dexamethasone group compared to the control group (p < 0.039, 0.024, 0.032) respectively. Prophylactic intravenous dexamethasone in a dose of 0.2 mg/kg can reduce the incidence of postoperative sore throat after extubation with minimal side effects.

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.

Reducing antibiotic prescribing in Australian general practice: time for a national strategy

In Australia, the antibiotic resistance crisis may be partly alleviated by reducing antibiotic use in general practice, which has relatively high prescribing rates - antibiotics are mostly prescribed for acute respiratory infections, for which they provide only minor benefits. Current surveillance is inadequate for monitoring community antibiotic resistance rates, prescribing rates by indication, and serious complications of acute respiratory infections (which antibiotic use earlier in the infection may have averted), making target setting difficult. Categories of interventions that may support general practitioners to reduce prescribing antibiotics are: regulatory (eg, changing the default to "no repeats" in electronic prescribing, changing the packaging of antibiotics to facilitate tailored amounts of antibiotics for the right indication and restricting access to prescribing selected antibiotics to conserve them), externally administered (eg, academic detailing and audit and feedback on total antibiotic use for individual GPs), interventions that GPs can individually implement (eg, delayed prescribing, shared decision making, public declarations in the practice about conserving antibiotics, and self-administered audit), supporting GPs' access to near-patient diagnostic testing, and public awareness campaigns. Many unanswered clinical research questions remain, including research into optimal implementation methods. Reducing antibiotic use in Australian general practice will require a range of approaches (with various intervention categories), a sustained effort over many years and a commitment of appropriate resources and support.

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.

Effect of Oral Prednisolone on Symptom Duration and Severity in Nonasthmatic Adults With Acute Lower Respiratory Tract Infection: A Randomized Clinical Trial

IMPORTANCE

Acute lower respiratory tract infection is common and often treated inappropriately in primary care with antibiotics. Corticosteroids are increasingly used but without sufficient evidence.

OBJECTIVE

To assess the effects of oral corticosteroids for acute lower respiratory tract infection in adults without asthma.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, placebo-controlled, randomized trial (July 2013 to final follow-up October 2014) conducted in 54 family practices in England among 401 adults with acute cough and at least 1 lower respiratory tract symptom not requiring immediate antibiotic treatment and with no history of chronic pulmonary disease or use of asthma medication in the past 5 years.

INTERVENTIONS

Two 20-mg prednisolone tablets (n = 199) or matched placebo (n = 202) once daily for 5 days.

MAIN OUTCOMES AND MEASURES

The primary outcomes were duration of moderately bad or worse cough (0 to 28 days; minimal clinically important difference, 3.79 days) and mean severity of symptoms on days 2 to 4 (scored from 0 [not affected] to 6 [as bad as it could be]; minimal clinically important difference, 1.66 units). Secondary outcomes were duration and severity of acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, and adverse events.

RESULTS

Among 401 randomized patients, 2 withdrew immediately after randomization, and 1 duplicate patient was identified. Among the 398 patients with baseline data (mean age, 47 [SD, 16.0] years; 63% women; 17% smokers; 77% phlegm; 70% shortness of breath; 47% wheezing; 46% chest pain; 42% abnormal peak flow), 334 (84%) provided cough duration and 369 (93%) symptom severity data. Median cough duration was 5 days (interquartile range [IQR], 3-8 days) in the prednisolone group and 5 days (IQR, 3-10 days) in the placebo group (adjusted hazard ratio, 1.11; 95% CI, 0.89-1.39; P = .36 at an α = .05). Mean symptom severity was 1.99 points in the prednisolone group and 2.16 points in the placebo group (adjusted difference, -0.20; 95% CI, -0.40 to 0.00; P = .05 at an α = .001). No significant treatment effects were observed for duration or severity of other acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, or nonserious adverse events. There were no serious adverse events.

CONCLUSIONS AND RELEVANCE

Oral corticosteroids should not be used for acute lower respiratory tract infection symptoms in adults without asthma because they do not reduce symptom duration or severity.

TRIAL REGISTRATION

ISRCTN.com Identifier: ISRCTN57309858.

Stakeholders' views of recurrent sore throat, tonsillitis and their management: a qualitative interview study for the NAtional Trial of Tonsillectomy IN Adults (NATTINA Part 1)

OBJECTIVES

To determine the impact of recurrent sore throats and tonsillitis in adults and stakeholder views of treatment pathways.

DESIGN

Qualitative semistructured interview design reporting novel data from a feasibility study for a UK national trial of tonsillectomy in adults.

SETTING

Nine study sites linked to ear, nose and throat departments in National Health Service hospitals located across the United Kingdom.

PARTICIPANTS

Fifteen patients, 11 general practitioners and 22 ear, nose and throat staff consented to in-depth interviews, which were analysed using a framework analysis approach.

MAIN OUTCOME MEASURES

Views of stakeholder groups.

RESULTS

Recurrent sore throats were reported to severely impact patients' family, work and social life. Ear, nose and throat staff stated that patients faced increasing barriers to secondary care service access. General practitioners were under pressure to reduce 'limited clinical value' surgical procedures.

CONCLUSIONS

The findings from this study suggest that there is a disconnect between the attitudes of the stakeholders and the reality of recurrent sore throat, tonsillectomy procedures and service provision. More evidence for the role of tonsillectomy is needed from randomised controlled trials to determine whether it should continue to be ranked as a procedure of limited clinical effectiveness.

The Efficacy of Corticosteroids in the Treatment of Peritonsillar Abscess: A Meta-Analysis

Despite widespread use of antibiotics and surgical procedures for treating peritonsillar abscess (PTA), symptoms of severe inflammation such as pain and trismus during treatment result in patient dissatisfaction. The goal of this study was to perform a systematic review and meta-analysis of the efficacy of systemic steroids on the clinical course of PTA. Two reviewers independently searched the databases (MEDLINE, Scopus, and the Cochrane Database) from inception to December 2014. Studies comparing systemic administration of steroids (steroid group) with placebo (placebo group), where the outcomes of interest were pain, body temperature, hospitalization, and oral intake during the posttreatment period, were included. Baseline study characteristics, study quality data, numbers of patients in the steroid and control groups, and outcomes were extracted. Sufficient data for meta-analysis were retrieved for 3 trials with a total of 153 patients. Pain-related parameters (patient-reported scores and trismus), body temperature, and dysphagia during the first 24 hours after treatment were significantly improved in the steroid group compared with placebo group. The discharge rate during the first 5 days of the posttreatment period was significantly higher in the steroid group than the control group. However, although more patients in the steroid group returned to normal activities and dietary intake at 24 hours after treatment, the differences between the groups were not significant and disappeared after 48 hours. In the treatment of PTA, systemic administration of steroids with antibiotics could reduce pain-related symptoms, as well as provide a benefit with respect to the clinical course. However, further trials with well-designed research methodologies should be conducted to confirm our results.

Efficacy and safety of Qi-Wei-Qing-Yan aerosol in treatment of acute pharyngitis (lung-stomach excess-heat syndrome): study protocol for a randomized controlled trial

Background

Acute pharyngitis accounts for an estimated 15 million patient visits in the United States. However, there is no proven effective and safe treatment. Although Chinese herbal medicine is widely used in the treatment of acute pharyngitis, there is a lack of evidence-based data. Despite several clinical trials conducted in this setting, no randomized placebo-controlled trial has been performed to date. This trial aims to investigate the efficacy and safety of Qi-Wei-Qing-Yan aerosol (QWQYA), a Chinese herbal prescription, compared with a placebo aerosol in the treatment of acute pharyngitis with lung-stomach excess-heat syndrome.

Methods/design

This is a prospective, multicenter, randomized, double-blinded, parallel-group, placebo-controlled trial. A total of 420 adult patients, of either sex, with acute pharyngitis will be enrolled from seven study sites across China. All patients will be randomly allocated to one of three parallel treatment groups: (1) QWQYA with the current propellant, (2) QWQYA with a previous propellant, and (3) the placebo aerosol with the current propellant. The study medication will be administered into the pharyngeal region in three sprays thrice daily for 5 consecutive days. The primary outcome measures are time to complete resolution of sore throat and relief rate of sore throat. Secondary outcome measures include resolution rate of sore throat, time to relief of sore throat, intensity of sore throat, and change of traditional Chinese medicine syndrome score and clinical signs score from baseline to post-treatment, as well as the occurrence of any adverse events.

Discussion

This will be the first clinical trial to investigate the efficacy and safety of QWQYA in the treatment of acute pharyngitis in an adult population in a multicenter, randomized, double-blinded, parallel-group, placebo-controlled manner. Not only might it establish the basis for the efficacy and safety of QWQYA in treating acute pharyngitis, but it might also provide evidence to support the use of Chinese herbal medicine in treating acute pharyngitis and thus support an alternative treatment option for management of acute pharyngitis.

Trial registration

Chinese Clinical Trial Registry ChiCTR-IPR-15005991.

Corticosteroids for the common cold

BACKGROUND

The common cold is a frequent illness, which, although benign and self limiting, results in many consultations to primary care and considerable loss of school or work days. Current symptomatic treatments have limited benefit. Corticosteroids are an effective treatment in other upper respiratory tract infections and their anti-inflammatory effects may also be beneficial in the common cold. This updated review has included one additional study.

OBJECTIVES

To compare corticosteroids versus usual care for the common cold on measures of symptom resolution and improvement in children and adults.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 4), which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) (2015, Issue 2), NHS Health Economics Database (2015, Issue 2), MEDLINE (1948 to May week 3, 2015) and EMBASE (January 2010 to May 2015).

SELECTION CRITERIA

Randomised, double-blind, controlled trials comparing corticosteroids to placebo or to standard clinical management.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We were unable to perform meta-analysis and instead present a narrative description of the available evidence.

MAIN RESULTS

We included three trials (353 participants). Two trials compared intranasal corticosteroids to placebo and one trial compared intranasal corticosteroids to usual care; no trials studied oral corticosteroids. In the two placebo-controlled trials, no benefit of intranasal corticosteroids was demonstrated for duration or severity of symptoms. The risk of bias overall was low or unclear in these two trials. In a trial of 54 participants, the mean number of symptomatic days was 10.3 in the placebo group, compared to 10.7 in those using intranasal corticosteroids (P value = 0.72). A second trial of 199 participants reported no significant differences in the duration of symptoms. The single-blind trial in children aged two to 14 years, who were also receiving oral antibiotics, had inadequate reporting of outcome measures regarding symptom resolution. The overall risk of bias was high for this trial. Mean symptom severity scores were significantly lower in the group receiving intranasal steroids in addition to oral amoxicillin. One placebo-controlled trial reported the presence of rhinovirus in nasal aspirates and found no differences. Only one of the three trials reported on adverse events; no differences were found. Two trials reported secondary bacterial infections (one case of sinusitis, one case of acute otitis media; both in the corticosteroid groups). A lack of comparable outcome measures meant that we were unable to combine the data.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of intranasal corticosteroids for symptomatic relief from the common cold. However, there were only three trials, one of which was very poor quality, and there was limited statistical power overall. Further large, randomised, double-blind, placebo-controlled trials in adults and children are required to answer this question.

Pharyngitis: soothing the sore throat

Sore throat is a common presentation in primary care. Accurate identification of cause is important for appropriate treatment. Clinical scoring systems and diagnostic tests are recommended to identify group A beta-hemolytic streptococcus, which warrants guideline-driven therapy. The article explores causes, diagnosis, management, and possible complications of pharyngitis.

Can oral corticosteroids reduce the severity or duration of an acute cough, and the associated National Health Service and societal costs, in adults presenting to primary care? Study protocol for a randomised controlled trial

BACKGROUND

Acute lower respiratory tract infection (LRTI) is one of the most common conditions managed internationally and is costly to health services and patients. Despite good evidence that antibiotics are not effective for improving the symptoms of uncomplicated LRTI, they are widely prescribed, contributing to antimicrobial resistance. Many of the symptoms observed in LRTI are mediated by inflammatory processes also observed in exacerbations of asthma, for which there is strong evidence of corticosteroid effectiveness. The primary aim of the OSAC (Oral Steroids for Acute Cough) Trial is to determine whether oral prednisolone (40 mg daily for 5 days) can reduce the duration of moderately bad (or worse) cough and the severity of all its associated symptoms on days 2 to 4 post-randomisation (day 1 is trial entry) by at least 20% in adults ≥18 years with acute LRTI presenting to primary care.

METHODS/DESIGN

OSAC is a two-arm, multi-centre, placebo-controlled, randomised superiority trial. The target sample size is 436 patients, which allows for a 20% dropout rate. Patients will be recruited from primary care sites (General Practitioner surgeries) across England and followed up until symptom resolution. The two primary clinical outcomes are the duration of moderately bad (or worse) cough, and the severity of all its associated symptoms on days 2 to 4 post-randomisation. Secondary outcomes include: antibiotic consumption; symptom burden; adverse events; participant satisfaction with treatment and intention to consult for future similar illnesses. A parallel economic evaluation will investigate the cost-effectiveness of the intervention.

DISCUSSION

Results from the OSAC trial will increase knowledge regarding the clinical and cost-effectiveness of corticosteroids for LRTI, and will establish the potential of a new treatment option that could substantially improve patient health. We have chosen a relatively high 'efficacy dose' as this will enable us to decide on the potential for further research into lower dose oral and/or inhaled corticosteroids. This trial will also contribute to a growing body of research investigating the natural course of this very common illness, as well as the effects of steroids on the undesirable inflammatory symptoms associated with infection.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN57309858 (31 January 2013).

The efficacy of systemic corticosteroids in treatment of respiratory tract infections during hajj 2012

BACKGROUND

Diagnosis and treatment of respiratory tract infections (RTI) in a mass-gathering situation such as hajj is a medical challenge that requires quick decision-making and considerable knowledge about its etiology and treatment methods. High prevalence of RTI during Hajj and tendency of caravan physicians to treat of patients quickly in such situation lead to prescription of parenteral steroids. Nonetheless, no study has focused on the short-term and long-term effects of systemic steroids in Hajj pilgrims with RTI.

OBJECTIVES

This study focuses on efficacy of systemic consumption of corticosteroids in alleviating symptoms of RTI.

PATIENTS AND METHODS

This clinical trial was included 1671 pilgrims in Hajj 2012 who had symptoms of RTI based on caravan physician's findings. The patients were divided to two groups to receive either parenteral corticosteroid or other drugs. Patients who received antibiotics for bacterial infections were excluded. This survey concentrated on general symptoms of RTI during Hajj such as fever, musculoskeletal pain, coryza, sore throat, cough, dyspnea, and hoarseness before, 24 hours after, and five days after drug consumption. For classification and analysis of data, SPSS 17 was used. Descriptive statistical and Chi square test were used to compare variables.

RESULTS

In comparison to corticosteroid injection, treatment without systemic corticosteroids could reduce the fever more significantly within five days (P < 0.05), while it had no effect after 48 hours (P > 0.05). Although corticosteroids alleviated the symptoms during the first 48 hours (P > 0.05), they had no more effect after five days of consumption (P > 0.05). Treatment with medications other than corticosteroid had less effect on reducing coryza (P > 0.05) while corticosteroids had significant alleviating effect on coryza, cough, and musculoskeletal pain (P < 0.05).

CONCLUSIONS

There is a need to conduct more comprehensive studies on effect of combination therapy with corticosteroids and antibiotics as well as their short-term and long-term adverse effects on the immune system. While injecting corticosteroids is commonly administered in patients with RTI, they are not recommended due to the lack of data on their long-term therapeutic and adverse effects.

Tonsillitis and sore throat in children

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.

Oral corticosteroid use for clinical and cost-effective symptom relief of sore throat: study protocol for a randomized controlled trial

BACKGROUND

Management of acute sore throat poses a significant burden on UK general practices, with almost 10% of registered patients attending their GP with sore throat every year. Nearly half of all patients presenting with acute sore throat are treated with antibiotics, despite their limited effect. In a recent systematic review we demonstrated that a single dose of steroids reduced the severity and time to resolution of sore throat. However, all of the trials included looked at the use of steroids alongside antibiotics and only one was in a primary care setting. This trial aims to assess the efficacy and cost-effectiveness of a single oral dose of corticosteroids on symptoms of sore throat in patients receiving either a delayed antibiotic prescription or no antibiotics at all in UK primary care.

METHODS/DESIGN

A double-blind, two arm, randomized, placebo controlled trial in adults (≥ 18 years of age) presenting to primary care with acute sore throat (

DISCUSSION

This will be the first randomized controlled trial of oral corticosteroids in adults presenting to primary care with sore throat in the UK, and the first to examine the clinical and cost-effectiveness of oral corticosteroids for the treatment of sore throat in the absence of antibiotics.

TRIAL REGISTRATION

This trial is registered with Current Controlled Trials on 26 March 2013, registration number: ISRCTN17435450.

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Key Words

• sore throat
• steroid
• antibiotics
• delayed antibiotic prescription
• dexamethasone
• same day recruitment
• adults
• randomized
• placebo-controlled

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MESH Headings

• Administration, Oral
• Adrenal Cortex Hormones/administration & dosage
• Adrenal Cortex Hormones/economics
• Anti-Bacterial Agents/administration & dosage
• Clinical Protocols
• Cost-Benefit Analysis
• Dexamethasone/administration & dosage
• Dexamethasone/economics
• Double-Blind Method
• Drug Costs
• Drug Therapy, Combination
• England
• Female
• Humans
• Male
• Pharyngitis/diagnosis
• Pharyngitis/drug therapy
• Pharyngitis/economics
• Pharyngitis/microbiology
• Primary Health Care/economics
• Research Design
• Time Factors
• Treatment Outcome
• Unnecessary Procedures/economics

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Grants

• NIHR-RP-02-12-012 Department of Health

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Affiliation(s)

Johanna Cook />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Gail Hayward />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Matthew Thompson />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK />Department of Family Medicine, University of Washington, 1959 Ne Pacific St, Seattle, WA 98195 USA
Alastair D Hay />Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
Michael Moore />Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST UK
Paul Little />Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST UK
Kim Harman />Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
Jane Wolstenholme />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Rafael Perera />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Merryn Voysey />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Julie Allen />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Maria Breen />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
Carl Heneghan />Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK

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Comparing the Effect of Dexamethasone before and after Tracheal Intubation on Sore Throat after Tympanoplasty Surgery: A Randomized Controlled trial

INTRODUCTION

Presence of a sore throat after surgery is a common side effect of general anesthesia with intratracheal intubation and can cause discomfort for the patient and prolong the recovery process. In this study we compared the effect of dexamethasone before and after intubation on the incidence of sore throat after tympanoplasty surgery.

MATERIALS AND METHODS

In a double-blind, randomized clinical trial, 70 patients aged 30-60 years with American Society of Anesthesiologists (ASA) physical status I or II who were candidates for tympanoplasty under anesthetic conditions were studied in two separate groups. The first group received intravenous (IV) dexamethasone (8 mg) 30 mins prior to intubation while the second group received the same dose of dexamethasone 30 mins after intubation. The incidence and severity of the sore throat in both groups were then evaluated.

RESULTS

There was no significant difference between two groups in intensity of sore throat (62.9% vs. 57.1%), cough (65.7% vs. 62.9%), or hoarseness (62.9% vs. 65.7%) within 24 h after surgery. Detection of blood in oral secretions or on the tracheal tube was the same in both groups (5.7%). The incidence of coughs during the extubation was 0% in first group and 11.4% in second group.

CONCLUSION

According to the results of this research there was no significant difference in incidence and intensity of sore throat in patients receiving dexamethasone before or after intubation. Further, no significant difference in intensity of coughs or hoarseness was observed.

Systemic corticosteroids for acute sinusitis

BACKGROUND

Acute sinusitis is the inflammation and swelling of the nasal and paranasal mucous membranes and is a common reason for patients to seek primary care consultations. The related impairment of daily functioning and quality of life is attributable to symptoms such as facial pain and nasal congestion.

OBJECTIVES

To assess the effects of systemic corticosteroids on clinical response rates and to determine adverse effects and relapse rates of systemic corticosteroids compared to placebo or standard clinical care in children and adults with acute sinusitis.

SEARCH METHODS

We searched CENTRAL (2014, Issue 1), MEDLINE (1966 to February week 1, 2014) and EMBASE (January 2009 to February 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic corticosteroids to placebo or standard clinical care for patients with acute sinusitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of the trials and extracted data.

MAIN RESULTS

Five RCTs with a total of 1193 adult participants met our inclusion criteria. We judged methodological quality to be moderate in four trials and high in one trial. Acute sinusitis was defined clinically in all trials. However, the three trials performed in ear, nose and throat (ENT) outpatient clinics also used radiological assessment as part of their inclusion criteria. All participants were assigned to either oral corticosteroids (prednisone 24 mg to 80 mg daily or betamethasone 1 mg daily) or the control treatment (placebo in four trials and non-steroidal anti-inflammatory drugs (NSAIDs) in one trial). In four trials antibiotics were prescribed in addition to oral corticosteroids or control treatment, while one trial investigated the effects of oral corticosteroids as a monotherapy.When combining data from the five trials, participants treated with oral corticosteroids were more likely to have short-term resolution or improvement of symptoms than those receiving the control treatment: at days three to seven (risk ratio (RR) 1.3, 95% confidence interval (CI) 1.1 to 1.6; risk difference (RD) 17%, 95% CI 6% to 29%) and at days four to 14 (RR 1.2, 95% CI 1.0 to 1.5; RD 14%, 95% CI 1% to 27%). A sensitivity analysis including the four trials with placebo as a control treatment showed similar results but with a lesser effect size: at days three to seven (RR 1.2, 95% CI 1.1 to 1.3; RD 11%, 95% CI 4% to 17%) and days four to 14 (RR 1.1, 95% CI 1.0 to 1.2; RD 8%, 95% CI 2% to 13%). Statistical heterogeneity was high for many analyses. Subgroup analyses revealed that corticosteroid monotherapy had no beneficial effects. Furthermore, scenario analysis showed that outcomes missing from the trial reports might have introduced attrition bias (a worst-case scenario showed no statistically significant beneficial effect of oral corticosteroids). No trial reported effects on relapse or recurrence rates. Reported side effects in patients treated with oral corticosteroids were mild (nausea, vomiting, gastric complaints) and did not significantly differ from those receiving placebo.

AUTHORS' CONCLUSIONS

Oral corticosteroids as a monotherapy appear to be ineffective for adult patients with clinically diagnosed acute sinusitis. Current data on the use of oral corticosteroids as an adjunctive therapy to oral antibiotics are limited: almost all trials are performed in secondary care settings and there is a significant risk of bias. This limited evidence suggests that oral corticosteroids in combination with antibiotics may be modestly beneficial for short-term relief of symptoms in acute sinusitis, with a number needed to treat to benefit of seven for resolution or symptom improvement. A large primary care factorial trial is needed to establish whether oral corticosteroids offer additional benefits over antibiotics in acute sinusitis.

Corticosteroids for acute and subacute cough following respiratory tract infection: a systematic review

BACKGROUND

Cough associated with acute respiratory tract infection (RTI) is one of the most common problems managed in primary care. Despite minimal evidence for the use of antibiotics, they continue to be prescribed at great cost and are a significant cause of emerging bacterial resistance.

OBJECTIVES

To carry out a systematic review of randomized controlled trials to evaluate the effect of corticosteroid therapy in otherwise-healthy adults with acute RTI.

METHODS

Seven electronic databases and five ongoing trial registers were searched. Studies were eligible if they compared the use of any corticosteroid treatment against a control group in adults with an acute (<3 weeks) or subacute (<8 weeks) cough associated with an RTI but no asthma. Primary outcomes were differences in mean cough and other symptom scores. Secondary outcomes included adverse effects, subsequent diagnosis of asthma and patient satisfaction.

RESULTS

Four trials (335 participants) investigating the effects of inhaled corticosteroids were identified. None investigated the use of oral corticosteroids. Results were mixed, with two reporting equivalence and two reporting benefits for mean cough score (P = 0.012) and cough frequency (P = 0.047). One reported additional benefits in non-smokers. Adverse events were rare and there were no data on patient satisfaction or the subsequent diagnosis of asthma. Most trials were of unclear risk of bias. Study outcomes were too heterogeneous to meta-analyse.

CONCLUSIONS

There is insufficient evidence to recommend the routine use of inhaled corticosteroids for acute RTI in adults. However, some trials have shown benefits, suggesting the need for further high-quality, adequately powered trials.

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.

OBJECTIVES

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

SEARCH METHODS

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 5) which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects and the NHS Health Economics Database, MEDLINE (1966 to November Week 4, 2012) and EMBASE (1974 to June 2012).

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed and selected trials from searches, assessed and rated study quality, and extracted relevant data.

MAIN RESULTS

We included eight trials involving 743 participants (369 children and 374 adults). All trials gave antibiotics to both placebo and corticosteroid groups; no trials assessed corticosteroids as standalone treatment for sore throat. In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by more than three times (risk ratio (RR) 3.2, 95% confidence interval (CI) 2.0 to 5.1, P < 0.001, I(2) statistic 44%) and at 48 hours by 1.7 times. Fewer than four 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 14 hours, respectively, although significant heterogeneity was present. At 24 hours, pain (assessed by visual analogue scores) was reduced by an additional 14% by corticosteroids. No difference in rates of recurrence, relapse or adverse events were reported for participants taking corticosteroids compared to placebo, although reporting of adverse events was poor.

AUTHORS' CONCLUSIONS

Oral or intramuscular corticosteroids, in addition to antibiotics, increase the likelihood of both resolution and improvement of pain in participants with sore throat. Further trials assessing corticosteroids in the absence of antibiotics and in children are warranted.

No evidence for the effectiveness of systemic corticosteroids in acute pharyngitis, community-acquired pneumonia and acute otitis media

Corticosteroids have been used to treat infectious diseases for more than 50 years but, although it has been shown that they are highly effective in improving the clinical course of some diseases, their effects have not been clearly defined in others. Nevertheless, they are still used by a considerable number of physicians. This review analyses the role of systemic corticosteroids in the treatment of acute pharyngitis (AP), community-acquired pneumonia (CAP) and acute otitis media (AOM). A number of trials involving patients with AP have been carried out, but most are marred by methodological flaws that do not allow any firm conclusions to be drawn. The number of trials involving CAP patients is even higher, and the data suggest that corticosteroids may reduce the risk of death only in patients with severe disease. There are very few data concerning AOM, and there is currently no reason for prescribing corticosteroids to treat it. Overall, the data showed that there is, currently, no indication for the universal use of systemic corticosteroids in any of the reviewed diseases and, further, high-quality studies of all of these respiratory tract infections are needed in order to identify the patients for whom the prescription of corticosteroids is rationally acceptable.

Corticosteroids for the common cold

BACKGROUND

The common cold is a frequent illness, which, although benign and self-limiting, results in many consultations to primary care and considerable loss of school or work days. Current symptomatic treatments have limited benefit. Corticosteroids are an effective treatment in other upper respiratory tract infections and their anti-inflammatory effects may also be beneficial in the common cold.

OBJECTIVES

To compare corticosteroids versus usual care for the common cold on clinical response rates in children and adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 5 which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) 2012, Issue 4 and the NHS Health Economics Database 2012, Issue 5; MEDLINE (1948 to May week 2, 2012) and EMBASE (January 2010 to May 2012).

SELECTION CRITERIA

Randomised, double-blind, controlled trials comparing corticosteroids to placebo or to standard clinical management.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We were unable to perform meta-analysis and instead analysed results using narrative description of the available evidence.

MAIN RESULTS

We included two trials (253 participants). Both compared intranasal corticosteroids to placebo; no trials studied oral corticosteroids. No benefit of intranasal corticosteroids was demonstrated for duration or severity of symptoms. In one trial of 54 participants, the number of symptomatic days was 10.3 in the placebo group, compared to 10.7 in those using intranasal corticosteroids (P = 0.72). A second trial of 199 participants reported no significant differences in duration of symptoms. There were no differences reported in terms of: adverse events; complications (one case of sinusitis, one case of acute otitis media, both in corticosteroid groups); presence of rhinovirus in nasal aspirates; or treatment for secondary infections. Neither trial reported our primary outcome measure of percentage of participants with resolution at different time points. A lack of comparable outcome measures meant we were unable to combine the data.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of intranasal corticosteroids for symptomatic relief from the common cold. However, there were only two trials and limited statistical power. Further large randomised placebo-controlled trials in adults and children are required to answer this question.

Adverse effects of steroid therapy in children with pharyngitis with unsuspected malignancy

Pharyngitis is a common clinical complaint for children and accounts for 3.1% of all visits to selected ambulatory care settings. Most children with pharyngitis have benign, self-limited disease with infrequent complications such as peritonsillar abscess, mastoiditis, or lymphadenitis. Recent studies have touted the benefits of steroids in the treatment of children with pharyngitis for pain control. These studies do not address the potential life-threatening complication of steroids in patients with pharyngitis or lymphadenopathy in the setting of undiagnosed acute lymphocytic leukemia (ALL) or lymphoma. We report 4 cases of children treated with steroids for pharyngitis or adenitis that subsequently were diagnosed with ALL or lymphoma. If steroids are to be used in children with pharyngitis or adenitis, the following recommendations should be strongly considered: Careful history and physical examination should be obtained. Presence of hepatosplenomegaly or lymphadenopathy outside the cervical region should raise suspicions regarding an underlying malignancy. Normal results of complete blood cell count in the setting of clear cut pharyngitis with exudates and a lack of significant adenopathy essentially rules out the diagnosis of ALL. Because traditional analgesics are available, which do not affect the curability of ALL or lymphoma, the routine use of steroids in pharyngitis in children should be considered only in rare circumstances.

Guideline for the management of acute sore throat

The European Society for Clinical Microbiology and Infectious Diseases established the Sore Throat Guideline Group to write an updated guideline to diagnose and treat patients with acute sore throat. In diagnosis, Centor clinical scoring system or rapid antigen test can be helpful in targeting antibiotic use. The Centor scoring system can help to identify those patients who have higher likelihood of group A streptococcal infection. In patients with high likelihood of streptococcal infections (e.g. 3-4 Centor criteria) physicians can consider the use of rapid antigen test (RAT). If RAT is performed, throat culture is not necessary after a negative RAT for the diagnosis of group A streptococci. To treat sore throat, either ibuprofen or paracetamol are recommended for relief of acute sore throat symptoms. Zinc gluconate is not recommended to be used in sore throat. There is inconsistent evidence of herbal treatments and acupuncture as treatments for sore throat. Antibiotics should not be used in patients with less severe presentation of sore throat, e.g. 0-2 Centor criteria to relieve symptoms. Modest benefits of antibiotics, which have been observed in patients with 3-4 Centor criteria, have to be weighed against side effects, the effect of antibiotics on microbiota, increased antibacterial resistance, medicalisation and costs. The prevention of suppurative complications is not a specific indication for antibiotic therapy in sore throat. If antibiotics are indicated, penicillin V, twice or three times daily for 10 days is recommended. At the present, there is no evidence enough that indicates shorter treatment length.

Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis

PURPOSE

Acute sinusitis is a common condition in ambulatory care, where it is frequently treated with antibiotics, despite little evidence of their benefit. Intranasal corticosteroids might relieve symptoms; however, evidence for this benefit is currently unclear. We performed a systematic review and meta-analysis of the effects of intranasal corticosteroids on the symptoms of acute sinusitis.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central register of Controlled Trials (CENTRAL), and Centre for Reviews and Dissemination databases until February 2011 for studies comparing intranasal corticosteroids with placebo in children or adults having clinical symptoms and signs of acute sinusitis or rhinosinusitis in ambulatory settings. We excluded chronic/allergic sinusitis. Two authors independently extracted data and assessed the studies' methodologic quality.

RESULTS

We included 6 studies having a total of 2,495 patients. In 5 studies, antibiotics were prescribed in addition to corticosteroids or placebo. Intranasal corticosteroids resulted in a significant, small increase in resolution of or improvement in symptoms at days 14 to 21 (risk difference [RD] = 0.08; 95% CI, 0.03-0.13). Analysis of individual symptom scores revealed most consistently significant benefits for facial pain and congestion. Subgroup analysis by time of reported outcomes showed a significant beneficial effect at 21 days (RD = 0.11; 95% CI, 0.06-0.17), but not at 14 to 15 days (RD = 0.05; 95% CI, -0.01 to 0.11). Meta-regression analysis of trials using different doses of mometasone furoate showed a significant dose-response relationship (P=.02).

CONCLUSIONS

Intranasal corticosteroids offer a small therapeutic benefit in acute sinusitis, which may be greater with high doses and with courses of 21 days' duration. Further trials are needed in antibiotic-naïve patients.

Steroids as adjuvant treatment of sore throat in acute bacterial pharyngitis

QUESTION

I see many children suffering from sore throat and acute pharyngitis. Some adult studies describe faster pain relief when sore throat is treated with steroids. Would a single dose of a steroid, as an anti-inflammatory agent, provide accelerated pain relief for sore throat in children?

ANSWER

A single dose of oral dexamethasone (0.6 mg/kg, maximum 10 mg) leads to significantly (P < .05) faster onset of pain relief and shorter suffering, especially in children with severe or exudative group A β-hemolytic streptococcus-positive acute pharyngitis.

Systemic corticosteroids for acute sinusitis

BACKGROUND

Acute sinusitis is a common reason for patients to seek primary care consultations. The related impairment of daily functioning and quality of life is attributable to symptoms such as facial pain and nasal congestion.

OBJECTIVES

To assess the effectiveness of systemic corticosteroids in relieving symptoms of acute sinusitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2011, which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) and the NHS Health Economics Database, MEDLINE (1966 to June week 2, 2011) and EMBASE (January 2009 to June 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic corticosteroids to placebo or standard clinical care for patients with acute sinusitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality of the trials and extracted data.

MAIN RESULTS

Four RCTs with a total of 1008 adult participants met our inclusion criteria. We judged studies to be of moderate methodological quality. Acute sinusitis was defined clinically in all trials. However, the three trials performed in ear, nose and throat (ENT) outpatient clinics also used radiological assessment as part of their inclusion criteria. All participants received oral antibiotics and were assigned to either oral corticosteroids (prednisone 24 mg to 80 mg daily or betamethasone 1 mg daily) or the control treatment (placebo in three trials and non-steroidal anti-inflammatory drugs (NSAIDs) in one trial). In all trials, participants treated with oral corticosteroids were more likely to have short-term resolution or improvement of symptoms than those receiving the control treatment: at Days 3 to 7, risk ratio (RR) 1.4, 95% CI 1.1 to 1.8; risk difference (RD) 20% (6% to 34%) and at Days 4 to 10 or 12, RR 1.3, 95% CI (1.0 to 1.7), RD 18% (3% to 33%). An analysis of the three trials with placebo as a control treatment showed similar results but with a lesser effect size: Days 3 to 6: RR 1.2, 95% CI (1.1 to 1.4), RD 12% (5% to 19%) and Days 4 to 10 or 12: RR 1.1, 95% CI (1.0 to 1.2), RD 10% (3% to 16%). Scenario analysis showed that outcomes missing from the trial reports might have introduced attrition bias (a worst-case scenario showed no statistically significant beneficial effect of oral corticosteroids). We did not identify any data on the long-term effects of oral corticosteroids on this condition, such as effects on relapse or recurrence rates. Reported side effects of oral corticosteroids were limited and mild.

AUTHORS' CONCLUSIONS

Current evidence suggests that oral corticosteroids as an adjunctive therapy to oral antibiotics are effective for short-term relief of symptoms in acute sinusitis. However, data are limited and there is a significant risk of bias. High quality trials assessing the efficacy of systemic corticosteroids both as an adjuvant and a monotherapy in primary care patients with acute sinusitis should be initiated.

Soothing a sore throat: the efficacy and safety of steroids in acute pharyngitis

BACKGROUND

Acute pharyngitis is a common presentation to Emergency Departments (EDs) and although most patients experience mild-to-moderate discomfort, severe pharyngitis can be incapacitating and painful. There have been recent trends in prescribing steroids to provide pain relief for patients with acute pharyngitis.

AIM

To examine the evidence for using steroids in adult patients with acute pharyngitis attending Emergency Departments.

METHODS

A comprehensive literature search was performed to identify randomised controlled trials, systematic reviews and meta-analyses. The primary outcome measure assessed was pain relief, while safety of steroids was chosen as a secondary outcome measure.

RESULTS

Six papers met the inclusion criteria--five randomised controlled clinical trials and one systematic review (adult and paediatric patients in a variety of clinical settings). Mean times to onset of pain relief were shorter in patients receiving steroids (8.1 vs. 19.9 h, 6.3 vs. 11.3 h, 6.3 vs. 12.4 h). A single study examining reduction in VAS pain scores found a statistically significant improvement in patients given steroids (PO: 4.2 ± 2.3, IM: 3.8 ± 2.3 vs placebo: 2.0). Marvez-Valls et al. reported shorter times to complete pain relief (43 vs. 36 h) but this and other studies failed to demonstrate a statistically significant reduction in the pain scores at 24 h. Frequency and nature of side effect reporting was inconsistent throughout the studies with no trials explicitly powered to detect clinically important adverse events.

CONCLUSION

Steroids may provide a useful adjunct in the management of acute pharyngitis, but there is currently insufficient evidence to endorse routine use.

Reducing uncertainty in managing respiratory tract infections in primary care

Respiratory tract infections (RTIs) remain the commonest reason for acute consultations in primary care in resource-rich countries. Their spectrum and severity has changed from the time that antibiotics were discovered, largely from improvements in the socioeconomic determinants of health as well as vaccination. The benefits from antibiotic treatment for common RTIs have been shown to be largely overstated. Nevertheless, serious infections do occur. Currently, no clinical features or diagnostic test, alone or in combination, adequately determine diagnosis, aetiology, prognosis, or response to treatment. This narrative review focuses on emerging evidence aimed at helping clinicians reduce and manage uncertainty in treating RTIs. Consultation rate and prescribing rate trends are described, evidence of increasing rates of complications are discussed, and studies and the association with antibiotic prescribing are examined. Methods of improving diagnosis and identifying those patients who are at increased risk of complications from RTIs, using clinical scoring systems, biomarkers, and point of care tests are also discussed. The evidence for alternative management options for RTIs are summarised and the methods for changing public and clinicians' beliefs about antibiotics, including ways in which we can improve clinician-patient communication skills for management of RTIs, are described.

Sore throat

INTRODUCTION

About 10% of people present to primary healthcare services with sore throat each year. The causative organisms of sore throat may be bacteria (most commonly Streptococcus) or viruses (typically rhinovirus), although it is difficult to distinguish bacterial from viral infections clinically.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to reduce symptoms of acute infective sore throat? What are the effects of interventions to prevent complications of acute infective sore throat? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 8 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, corticosteroids, non-steroidal anti-inflammatory drugs, paracetamol, and probiotics.

Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature

OBJECTIVES

The objective was to examine the effectiveness of corticosteroid treatment for the relief of pain associated with acute pharyngitis potentially caused by group A beta-hemolytic Streptococcus (GABHS).

METHODS

This was a systematic review of the literature. Data sources used were electronic databases (Cochrane Library, MEDLINE, EMBASE, Biosis Previews, Scopus, and Web of Science), controlled trial registration websites, conference proceedings, study references, experts in the field, and correspondence with authors. Selection criteria consisted of randomized controlled trials (RCTs) in which corticosteroids, alone or in combination with antibiotics, were compared to placebo or any other standard therapy for treatment of acute pharyngitis in adult patients, pediatric patients, or both. Two reviewers independently assessed for relevance, inclusion, and study quality. Weighted mean differences (WMDs) were calculated and are reported with corresponding 95% confidence intervals (CIs).

RESULTS

From 272 potentially relevant citations, 10 studies met the inclusion criteria. When compared to placebo, corticosteroids reduced the time to clinically meaningful pain relief (WMD = -4.54 hours; 95% CI = -7.19 to -1.89); however, they provided only a small reduction in pain scores at 24 hours (WMD = -0.90 on a 0-10 visual analog scale; 95% CI = -1.5 to -0.3). Heterogeneity among pooled studies was identified for both outcomes (I(2) = 81 and 74%, respectively); however, the GABHS-positive subgroup receiving corticosteroid treatment did have a significant mean reduction in time to clinically meaningful pain relief of 5.22 hours (95% CI = -7.02 to -3.42; I(2) = 0%). Short-term side effect profiles between corticosteroids and placebo groups were similar.

CONCLUSIONS

Corticosteroid administration for acute pharyngitis was associated with a relatively small effect in time to clinically meaningful pain relief (4.5-hour reduction) and in pain relief at 24 hours (0.9-point reduction), with significant heterogeneity in the pooled results. Decision-making should be individualized to determine the risks and benefits; however, corticosteroids should not be used as routine treatment for acute pharyngitis.

Primary care management of otitis media among Australian children

Acute otitis media (AOM) is diagnosed on the basis of acute onset of pain and fever; a red, bulging tympanic membrane; and middle ear effusion. AOM is managed with analgesia (paracetamol or non-steroidal anti-inflammatory drugs). Antibiotic therapy is minimally effective for most patients; it is most effective for children < 2 years with bilateral otitis media and for children with discharging ears. National guidelines recommend antibiotic therapy for Indigenous children with AOM. Evidence for corticosteroids, topical analgesia and xylitol are scant. Otitis media with effusion (OME) is diagnosed as the presence of middle ear effusion (type B tympanogram or immobile tympanic membrane on pneumatic otoscopy) without AOM criteria. Well children with OME with no speech and language delays can be observed for the first 3 months; perform audiological evaluation and refer to an ear, nose and throat (ENT) specialist if they have bilateral hearing impairment > 30 dB or persistent effusion. Children with effusions persisting longer than 3 months can benefit from a 2-4-week course of amoxycillin. Chronic suppurative otitis media is a chronic discharge through a tympanic membrane perforation. It is managed with regular ear cleaning (dry mopping or povidone-iodine [Betadine] washouts) until discharge resolves; topical ear drops (eg, ciprofloxacin); audiological evaluation; and ENT review.

Re-evaluation of antibiotic treatment of streptococcal pharyngitis

PURPOSE OF REVIEW

Recently, recommendations from the American Heart Association regarding treatment of streptococcal tonsillo-pharyngitis were revised. This review provides the background for changes that were made in comparison with the group's 1995 recommendations. Recent papers on other issues relating to group A Streptococcus are also reviewed.

RECENT FINDINGS

For antibiotic treatment of streptococcal tonsillopharyngitis the recommendations for injectable penicillin and for oral erythromycin are downgraded. First choice remains penicillin V but there is increasing acceptance of once-daily amoxicillin.

CONCLUSION

Streptococcal pharyngitis is still a major infectious disease seen in pediatric office practice. The main job of the practitioner is to make an accurate diagnosis and provide appropriate treatment in timely fashion in order to prevent acute rheumatic fever.