I look forward to your response.
We asked Professor Mark Thomas, Infectious Diseases Physician, Auckland DHB to respond to this question.
This letter about treatment of sore throats in people with a high risk of rheumatic fever draws attention to a probably
well-intentioned, but ultimately harmful, approach to the prevention of rheumatic fever. If a patient has been given
empiric antibiotics for a sore throat, but the subsequent throat swab result is negative for GAS, the antibiotics should
not be continued. This is emphasised in the most recent New Zealand Heart Foundation guidelines* for management of sore
throat, which very clearly state that antimicrobial treatment should promptly be stopped in people at high risk of rheumatic
fever, who present with a sore throat and who do not have GAS (Streptococcus pyogenes) isolated from a throat
swab. To advise such patients to continue with their antibiotic treatment is not consistent either with the widely accepted
New Zealand guidelines or with guidelines from other international authorities.
The advice to continue “treatment” of people who do not have GAS infection, with an antibiotic intended to eradicate
GAS infection, risks undermining confidence in the rational basis of the rheumatic fever prevention strategy. If clinicians
are advised to “treat” patients for an infection, that they have documented not to be present by the gold standard test,
then they may justifiably ask whether they are being encouraged to leave behind the practice of evidence-based medicine
and return to practices based on good intentions. Patients and their caregivers are also likely to lose confidence in
the wisdom of their health professionals and question why, if the results of the throat swab are to be ignored, the
test was performed in the first place?
Adherence to treatment for proven GAS infection is widely acknowledged to be problematic. If clinicians are encouraged
to “treat” non-existent infections, and patients and their families are encouraged to persist with “treatment” of non-existent
infections then the programme risks losing credibility, which will then increase the risk of patients and their caregivers
not persisting with treatment in those high risk patients who do have documented GAS infection.
The adverse effects of antibiotic treatment, whether immediate and minor, such as rash or gastrointestinal upset,
or immediate and severe, such as anaphylaxis, or more prolonged, such as selection of antibiotic resistant bacteria
or increased risk of obesity, occur regardless of whether the antibiotic was prescribed correctly or incorrectly. However,
those risks are very much less acceptable when the antibiotic prescription had no possibility of producing positive
The writer of this letter, and those faced with similar situations, should ask those giving them incorrect advice
about the management of sore throats, to carefully read the New Zealand Heart Foundation guidelines.
Associate Professor Mark Thomas
Faculty of Medical and Health Sciences
University of Auckland
* available from: www.heartfoundation.org.nz/uploads/sore_throat_guideline_14_10_06_FINAL-revised.pdf