Pharmacy First: Top tips for managing acute sore throats

CLINICAL UPDATE

The Pharmacy First service in England enables pharmacists to diagnose and treat seven specific conditions, which should hopefully reduce some of the current pressures on general practice. This series of guides assumes that pharmacists are familiar with the clinical pathways and requirements for Pharmacy First. The articles explore some key aspects of each service to support and enhance pharmacists’ knowledge.

Here, GP Dr Toni Hazell offers tips on managing acute sore throats in adults and children aged 5 years and over, in line with the Pharmacy First service.

A sore throat is a symptom, usually caused by an upper respiratory tract infection, the vast majority of which are viral in origin.¹ Patients often present with an opening gambit of ‘I’ve got tonsillitis’, but tonsillitis is a precise clinical diagnosis denoting inflammation of the tonsils – it isn’t synonymous with a sore throat. Sore throats will generally resolve within two weeks, whether caused by a bacteria or a virus, and most will clear more quickly than that – 40% by three days and 85% by one week.¹

Here are my top tips on how to assess and manage presentations of a sore throat appropriately and in line with the new Pharmacy First service. Note this service covers adults and children aged 5 years and over, excluding pregnant individuals under the age of 16.

1. Be alert for epiglottitis

Common things are common, and it is an old medical aphorism that when you hear hooves, you should think horses, not zebras.² Epiglottitis is a zebra that we all need to know about, and it’s right that the pathway puts the exclusion of epiglottitis at the top. It is a seriously scary condition, even when managed in hospital with full resuscitation equipment and an anaesthetist to hand, and mortality rates of up to 7% have been reported.³ See box 1 for more information about epiglottitis.

Box 1. About epiglottitis³

• Usually caused by the bacteria Haemophilus influenzae b (Hib), although may also be due to Streptococcal or Staphylococcus infection; incidence has decreased since vaccination against Hib: be . If you don’t have access to the medical record, be sure to ask about vaccination status.
• Causes significant swelling of the upper airways which can lead to respiratory arrest.
• The patient will sit upright, leaning forward, with their mouth open and will look worried. They won’t want to lie down.
• Look for the four D’s – drooling, dysphagia (difficulty swallowing), distress and dysphonia (altered voice).
• If you suspect epiglottitis, do NOT examine the throat as this can cause respiratory arrest. Keep the child sitting upright and call a blue light ambulance – they need to be in hospital immediately.

2. Exclude other signs of serious illness

It is important to rule out that a patient is unwell enough that they may need hospital treatment. The Pharmacy First pathway suggests pharmacists consider calculating NEWS2, an early warning score for sepsis. However, as highlighted in previous articles in this series it is important not to rely only on NEWS2.⁴ Pharmacists who are assessing patients will need to develop a feeling for when a patient looks unwell, backed up by physiological measurements. GPs sometimes call this their antenna twitching, or their ‘Spidey sense’; it builds over time.

Be concerned if a patient is sweaty or feels dizzy, is tachycardic or has a low blood pressure. Look for signs of dehydration, such as a dry mouth or skin, sunken eyes, or poor skin turgor – skin which doesn’t bounce back when pinched.⁵ This might be backed up by a history of poor oral intake, less urine output than normal, and feeling tired or dizzy.

While listening to what the patient says, also listen to how they say it. A ‘hot potato voice’⁶ (speech that sounds like you are trying to talk while holding a hot object in your mouth) should raise concerns – it could indicate epiglottitis, or a pharyngeal abscess, which would both require referral to secondary care.

3. Check if the patient has an abscess ^7-11

An abscess is an enclosed collection of pus in a tissue, organ or confined space in the body. The definitive treatment of an abscess is to let the pus out; for an abscess on the skin, this might be accomplished by waiting until it starts to ‘point’ or form a head, and then bursting it in a sterile way to drain the pus. Things are a bit more complicated if the abscess is in the throat, as there is always the risk of airway compromise.

A sore throat can, rarely, be a presentation of a peritonsillar abscess (next to the tonsils, also known as a quinsy), or a deeper abscess elsewhere in the pharynx. It’s not up to you to work out exactly where an abscess is, just to highlight the patients who might have one, as they will need hospital care. As with epiglottitis, these patients will look unwell; someone who isn’t a healthcare professional would probably be able to spot that they were ill. They may have a high temperature and severe pain in their throat and/or neck, and their voice might be muffled.

The classic sign of a quinsy is displacement of the uvula, which is pushed aside by the abscess and so doesn’t hang down straight in the back of the mouth (see image 1 below). Those with another type of pharyngeal abscess might have a noticeable large lump in their neck, not in the usual place for a lymph node. They may also have a hot potato voice and/or trismus, a spasm of the jaw muscles which makes it hard for them to open their mouth. Trismus is an unusual and serious sign; if seen, don’t persist with trying to examine, but get the patient to hospital.

Image 1. Quinsy or peritonsillar abscess (Science Photo Library)

4. Explore other causes of a sore throat

Differential diagnosis such as scarlet fever, glandular fever and cancer need to be kept in mind, so they are referred promptly to the GP. See box 2 for key features of these conditions.

Box 2. Differential diagnoses of a sore throat

Scarlet fever¹²

• Caused by the bacteria Streptococcus pyogenes, it is very contagious and often causes outbreaks in schools and nurseries.
• Most people will recover fully, but a few will experience complications. These may be mild, such as otitis media, or rarer and more severe, including rheumatic fever (leading to future heart valve disease) and glomerulonephritis, leading to kidney damage.
• Peak age is 2-8 years.
• The key clinical features are a sore throat, temperature >38.3°C and a characteristic rash (see image 2) with the following features:
  • Red in appearance, with pinpoint lesions.
  • Rough texture – often described as a ‘sandpaper rash’.
  • Starts on the trunk then spreads to the limbs, but spares the palms and soles.
  • Knee and elbow flexures and skin folds may have a darker red linear appearance known as Pastia’s lines.
  • Skin may peel after the rash resolves.

Image 2. Scarlet fever symptoms - classic rash on chest and abdomen (Science Photo Library)

• Other symptoms of scarlet fever include a white appearance of the tongue, which fades to leave a beefy red appearance, cervical lymphadenopathy, petechiae (pinpoint-sized spots) on the palate (image 3) and flushing of the face, with a pale area around the mouth (image 4).

Image 3. Scarlet fever symptoms - petechiae on the palate  (Science Photo Library)

Image 4. Scarlet fever symptoms – facial rash showing typical reddening of cheeks with a pale area around the mouth (Science Photo Library)

Glandular fever (infectious mononucleosis)¹³

• Caused by the Epstein-Barr virus and mainly spread through close contact, such as kissing or sharing cutlery or food.
• Presents with a sore throat and bilateral cervical lymph nodes which are tender and mobile. On examination there will often be enlarged and purulent tonsils with petechiae on the palate.
• The sore throat might have been preceded by a few days of general fatigue, with muscle aches, chills, headache and a loss of appetite.
• Most common in those aged 15-24 and unusual over the age of 40.
• Difficult to distinguish from other causes of sore throat, and commonly affects the age group in which tonsillitis is common. For this reason, ensure the patient is referred on to their GP if their sore throat does not clear up or they do not respond to treatment.

Cancer^14,15

• Head and neck cancers are the eighth commonest cancer in the UK, and more common in men than in women.
• Be alert for laryngeal cancer in those who are older and have a sore throat – the peak age is 70-74 and it is exceptionally uncommon under the age of 30. It is more common in smokers than non-smokers.
• Presentation is with a chronic history (more than three weeks) of a variety of symptoms, including sore throat, hoarse voice, pain on swallowing or difficulty swallowing, a lump in the neck or very bad breath.
• Remember this service is for acute - meaning short-lasting - sore throat, so any patient with persistent symptoms that could potentially be cancer should be advised to see their GP.

5. Self-care will usually be enough

Most people with an uncomplicated sore throat have a viral infection, which will not be helped by antibiotics.

One systematic review of antibiotic treatment of people presenting with sore throats found that you would need to treat 18 people with antibiotics to prevent one having a sore throat by day seven,¹⁶ and overall, antibiotics taken for seven days only shorten the symptom of a sore throat by 16 hours.¹⁷ If you are thinking about prescribing to prevent complications then the odds are even less in your favour – you’d need to treat 200 people to prevent one case of otitis media,  and 10,000 to treat one case of rheumatic fever.¹⁸

In contrast, for every 10 patients treated with antibiotics, one will be harmed by side-effects such as vomiting, diarrhoea or thrush,¹⁹ so for most patients, we would do more harm than good by acceding to their request for antibiotics.

6. Pus on the tonsils does not necessarily mean antibiotics are needed

It is increasingly common for patients to phone up their GP surgery and say that they have ‘white stuff’ on their tonsils, with an expectation that antibiotics will automatically be given. This may be related to practice during the Covid-19 pandemic, when some patients were asked to look in their own throat to guide prescribing decisions, due to the risks of attending surgery.

The Pharmacy First pathway recommends use of the FeverPAIN score based on a number of key symptoms, to help decide whether antibiotics are required, shown in box 3.

Box 3. The FeverPAIN scoring system

One point for each of:

• Fever (over 38°C).
• Purulence on the tonsils
• First Attendance within three days of onset of symptoms.
• Severely Inflamed tonsils
• No cough or coryza (cold symptoms).

Be careful how you interpret this score. For example, it is not clear what the definition of ‘severely inflamed tonsils’ is – inflammation generally presents with heat, swelling and redness,²⁰ so if the tonsils are enlarged and redder than you would expect, that would probably give the inflammation point in FeverPAIN.

Purulence is pus, or the ‘white stuff’ which patients describe to us – this can be seen in an examination of the throat with a torch.

In addition, although FeverPAIN rates how quickly the patient has presented, be mindful that most people working in primary care will have experience of being called for a sore throat of just a few hours duration, only to find the patient is completely well, has gone to work or school and has not even taken any analgesia over the counter.

It's also important to understand that a high FeverPAIN score doesn’t necessarily mean that the patient has a bacterial infection. Using a FeverPAIN threshold score ≥4 to consider prescribing antibiotics, as recommended by the Pharmacy First pathway, three out of 100 people with a sore throat might be given antibiotics, two of whom would not have a bacterial throat infection.²¹ Since most bacterial throat infections are self-limiting, this means many people being given antibiotics they don’t need. NICE advises that those with a FeverPAIN score of ≥4 only have a 62–65% chance of having a bacterial infection.¹⁷

This Pharmacy First flowchart therefore offers room to use your clinical judgement. For those with a FeverPAIN score of 0–3, self-care and over-the-counter pain relief are appropriate, with a suggestion that they return if there is no improvement in one week (score 0–1) or 3-5 days (2 or 3). For those with a score of 4 or 5, pain relief and self-care may still be appropriate if the symptoms are mild. ‘Mild symptoms’ aren’t defined, but consider whether the person is able to carry on with their usual activities of daily living and whether they have taken any analgesia before seeing you. Sharing the information above with them, so that they understand that in most cases they are more likely to be harmed than to benefit from antibiotics, may help them to make a choice for self-care.

Otherwise, if you and the patient both feel that antibiotics are warranted, then you would give five days of phenoxymethylpenicillin (or clarithromycin if they are allergic to penicillin and non-pregnant, or erythromycin if pregnant). The resources at TARGET RTI may be useful in these discussions²² and don’t ever forget that you are the professional, and your signature on a prescription (or electronic/PGD equivalent) carries professional and legal weight. Good healthcare professionals treat according to what patients need, not just what they want, so be prepared to say no if you don’t think that antibiotics are indicated.

7. Consider the patient’s wider medical history

As with most of the Pharmacy First pathways, patients who are immunosuppressed should be referred to their GP – this might be due to a disease (eg, a leukaemia or other blood cancer), or due to medication, which could be taken post-transplant or for the management of an inflammatory condition such as rheumatoid arthritis. Also be aware of the use of carbimazole  for overactive thyroid. Carbimazole can suppress the bone marrow, causing a low level of neutrophils, the white blood cells which fight infection. ²³ Patients who are on carbimazole are told to promptly report signs and symptoms of infection, particularly a sore throat, and they will need to have an urgent blood test done to check their neutrophil levels – this would generally mean that they need signposting back to their GP.

This is the latest in a series of articles on aspects of Pharmacy First from The Pharmacist.  

Dr Toni Hazell is a GP in north London