Pharmacy Strep A testing could reduce GP appointments for sore throats

A scheme involving point-of-care testing for group A streptococci in community pharmacy was able to limit antibiotic prescriptions to under 10% of patients, and could potentially reduce GP consultations for sore throat.

The findings come from a pilot study of a ‘test and treat’ service run in 35 Boots pharmacies across London and Leicestershire. As part of the service, patients were screened using the Centor scoring system; those meeting three or four of the Centor criteria were offered a throat swab to test for group A streptococci.

Of 367 patients who had an initial discussion with a member of staff in the pharmacy, 149 (40.6%) underwent throat swab testing and 36 (24.2%) tested positive for group A streptococci. These patients, who made up 9.8% of the initial population, all received antibiotics from the pharmacist.

“Such a service should reduce antibiotic pressure and the emergence of resistance, and further the aims of antibiotic control programmes,” the researchers write in the Journal of Antimicrobial Chemotherapy^[1]
(online, 20 July 2016).

The authors of the study, led by Peter Wilson, professor of microbiology at University College London, also found evidence that the scheme may have reduced unnecessary GP consultations.

The researchers gave study participants a questionnaire to complete. Of the 222 patients who responded, 97 (43.7%) said they would have seen a GP had the service not been available; 15 (15.5%) of these patients were provided with antibiotics and 31 (32.0%) were referred to their GP by the pharmacist because of atypical symptoms or a severe presentation (unilateral or chronic symptoms, signs of sepsis or recent antibiotics).

The team also found that among 123 patients who showed no signs of bacterial infection according to the Centor criteria (i.e. a score of 1 or 2), 60 (48.8%) said they would have gone to the GP about their symptoms.

Over the study period, the researchers estimate cost savings of £2,747 to the NHS through avoided GP consultations. If the service was extrapolated to the 1.2 million consultations for sore throats that GPs carry out each year in the UK, an additional 800,000 patients could be seen by community pharmacists instead.

The authors say that the impact on antimicrobial stewardship could be enhanced if the scheme was made more widely available through the NHS, as in its current form it is only accessible to those with sufficient funds. The service costs £7.50 for the test and £10.00 for antibiotics (when required). It currently operates in 56 Boots stores in the UK and Republic of Ireland.

Michael Moore, professor of primary care research at the University of Southampton, says that while the results of the study are interesting, he does not think there is sufficient evidence for the NHS to provide such a service.

However, he acknowledges: “It would appear from the results of this feasibility study that at least a proportion of patients self-referred and would have otherwise accessed their GP, so introduction of such a service may have positive effects both on demand and by reducing antibiotic use.”

Moore says it would be preferable to use the FeverPAIN criteria for screening purposes, rather than the Centor criteria. The FeverPAIN criteria were derived from a UK primary care population and screen for the presence of streptococcus C and G, Moore explains. By contrast, the Centor criteria were derived from an emergency room setting and only focus on streptococcus A.

Previous research^[2]
by Moore and his colleagues found that use of FeverPAIN criteria was as effective as group A streptococcal antigen testing, and that the addition of a point-of-care test provided no further benefit.

“If community pharmacies do press ahead with such a service it would be more efficient to use the FeverPAIN score since this should result in fewer patients progressing to a near patient test,” says Moore.

The authors of the current study suggest that, although FeverPAIN may be a more effective screening tool, point-of-care testing may help support conversations with patients in community settings about when the use of antibiotics is appropriate.

“UK primary care guidelines, however, still recommend the Centor scoring system for assessing sore throats and not point-of-care testing because of the limited evidence available,” they write.