Recently, ACP received a concern from an infectious diseases specialist who observed two instances where a patient with group A streptococcal pharyngitis (strep throat) was prescribed amoxicillin-clavulanate (amox-clav or Clavulin®) at a community pharmacy. In one case, the physician said the patient was told by the pharmacist that there is resistance to penicillin, and that it is not an appropriate choice. The physician is concerned that the pharmacists were prescribing unnecessarily broad-spectrum antibiotics (such as Clavulin®) and should be prescribing penicillin or amoxicillin as a first-line treatment for strep throat.
Pharmacist Susan Fryters agrees. Susan works in antimicrobial stewardship and infectious diseases at the Royal Alexandra Hospital in Edmonton. She is also the co-author and editor of Bugs & Drugs and co-founder of Do Bugs Need Drugs?, two resources to support antimicrobial stewardship.
She has some advice for pharmacists who are providing care for patients who are seeking treatment for sore throats.
“In children and adults, the majority of cases of sore throat or pharyngitis are caused by viruses,” said Susan. “There are some hallmark symptoms that would lead you to think that they have a viral cause of their sore throat versus bacterial, in which case a strep test isn’t necessary. These patients will get better on their own in two or three days. In patients who have classic or typical signs of a bacterial throat infection, a throat swab is necessary to see if they have group A strep. These patients should only be prescribed an antibiotic if they test positive for group A strep.”
If a patient tests positive for group A strep throat, Susan says the choice of antibiotic is clear.
“No matter what reference you look at, including Bugs & Drugs, it’s very clear that first-line therapy for group A strep is good old penicillin, or amoxicillin if the patient can’t take tablets (because we don’t have an oral penicillin suspension any longer),” said Susan. “So, for little kids who can’t take tablets, then you would prescribe amoxicillin oral suspension—these should be your drugs of choice.”
Susan also does not agree with the argument that there is resistance of group A strep to penicillin. She believes it should always be chosen as a first-line treatment for strep throat instead of broader-spectrum antibiotics.
“Worldwide there have been no documented cases of group A strep resistant to penicillin,” she said. “We’re not doing patients any favours by giving them a broader-spectrum antibiotic such as amox-clav, because they are more likely to develop adverse reactions from amox-clav than from penicillin or amoxicillin alone. It could also lead to resistance down the road in organisms carried in the throat other than group A strep.”
Ultimately, Susan reminds pharmacists that when a patient is seeking treatment for a sore throat, to be sure to ask the right questions and, if the symptoms call for it, perform a strep test before prescribing an antibiotic.
“Quite simply, if you’re not doing that test, you don’t know if the patient has a sore throat caused by a virus, which does not require antibiotic therapy or if they have group A strep throat,” she said. “You can’t make that diagnosis based on clinical presentation alone. If you don’t have the capability of doing that strep test in your pharmacy or can’t confirm the diagnosis of group A strep pharyngitis in the patient’s electronic health record (Netcare), I don’t think you should be prescribing an antibiotic. You should either refer the patient to a pharmacy that can do the test or to a physician to make the diagnosis.”
Remember, when performing point-of-care testing in the pharmacy, refer to the Standards of Practice for Laboratory and Point-of-Care Testing and the Guidelines for pharmacists and pharmacy technicians: Lab and Point-of-Care Testing.
