Survey of Spanish general practitioners’ attitudes toward management of sore throat: an internet-based questionnaire study

Conducting online surveys with health professionals has several benefits thereby making the web-based approach an attractive alternative to postal or telephone methods as they are easy to be implemented and allow large-scale surveys without postage costs [15]. Moreover, electronic surveys allow tighter control of the order in which respondents respond the different questions, thus preventing respondents from going back and changing their answers. Another advantage of electronic questionnaires is that data is automatically transferred to a database, thereby eliminating the need to enter the data manually and avoiding potential errors of data entry. However, the major obstacle is external validity, and specifically how to obtain a representative sample and adequate response rate [16]. As acknowledged in other studies, respondents to electronic surveys are usually unrepresentative of the whole community of health professionals even within a certain specialty such as primary care. In an online survey of a group of 800 web-using doctors in the UK, female doctors were found to be significantly underrepresented [17]. One cannot assume that registered members of a specific web site will necessarily reflect the whole group of these health professionals. In our study, the questionnaire was available in two scientific societies’ webpages and, in addition, demographic data were not requested in this questionnaire and therefore information about age and gender of the respondents is lacking. However, GPs were allowed to answer only once. The internet-based questionnaire may have introduced selection bias, as only internet users were invited to participate in the study. However, nearly all the GPs now have access to internet, at least in their workplace, since all the computers have access to internet throughout the country. Another difference is the gap between opinion and actual practice.

This was a study of opinions and perceptions which does not necessarily reflect the actual number of consultations due to acute pharyngitis and the real prescription habits. GPs clearly overestimated the number of acute episodes of sore throat as they admitted that this was the reason of encounter in one quarter of the consultations. This figure significantly contrasts with the percentages of episodes of acute pharyngitis reported in epidemiologic surveys. For instance, in a year-round study in two Spanish practices acute pharyngitis accounted for nearly 15% of the consultations due to an infectious disease [1]. In other studies, carried out in other countries, this percentage is even lower, ranging from 2 to 4% of the consultations seen by a family doctor [18, 19]. The present study clearly overestimates the physicians’ perceptions of how many episodes of acute pharyngitis they have retrospectively visited. Conversely, they tend to underestimate the percentages of cases in which an antibiotic is given [20]. As in other studies of opinions the results obtained do not accurately reflect what is in fact prescribed in primary offices, but rather correspond to hypothetical scenarios in which GPs were simply asked to give their opinion about each specific situation. This might explain why we only observed 32% of GPs who would prescribe antibiotics in the second case, describing a patient with two Centor criteria. Notwithstanding, on the basis of the results obtained in audit-based studies, a percentage ranging from 40 to 60% of the cases of pharyngitis and tonsillitis are being treated with antibiotics in Spain [8, 21]. However, in terms of what antibiotic would be used, the results obtained in this questionnaire-based study are similar to those obtained in other studies [8]. Another limitation, inherent to the Spanish healthcare system, is that we only considered when GPs think an antibiotic is warranted; however, since over-the-counter sale of antibiotics is still available, the actual consumption of antibiotics might be much higher [22].

Despite these weaknesses, this manuscript provides some insights about how GPs manage the treatment of cases of acute pharyngitis with the use of two clinical scenarios. One strength of this electronic survey, however, is the fact that this is one of the largest studies on public views of management of sore throat in Europe, despite only 5% of the members of both societies answering the questionnaire.

Patients with less than two Centor criteria have less than a 10% probability of having pharyngitis caused by group A β-haemolytic streptococcus while this probability ranges from 10 to 17% in patients with two criteria [3, 23]. Clinical guidelines endorsed by the most prestigious societies, such as the Infectious Diseases Society of America, the National Institute for Health and Clinical Excellence and the European Society of Clinical Microbiology and Infectious Diseases, do not recommend the utilisation of antibiotics for patients with sore throat and less than two Centor criteria [24‐26]. Despite the fact that guidelines also recommend the use of antibiotics in bacterial infections other than group A streptococcus, such as gonococcal infection, its incidence is very low in the primary care setting.

In a review of guidelines on sore throat in Europe and North America, Matthys et al. observed that of the ten national guidelines analysed, recommendations differed with regard to the use of a rapid antigen detection test and throat culture and with the indication for antibiotics. The North American, French, and Finnish guidelines considered diagnosis of GAS essential. In 4 of the 6 European guidelines, acute sore throat was considered a self-limiting disease and antibiotics were not recommended [27]. However, the review of the Cochrane Library recommends only the use antibiotics when streptococcal infection is suspected, since it has been demonstrated that antibiotic therapy reduces the number of complications [5]. Recently, Little et al. observed few complications in pharyngitis not treated with antibiotics, only 1.3% [28]. Most of the clinical guidelines, including those issued by the Infectious Society of North America and the Spanish guideline endorsed by GPs, recommend the use of rapid antigen detection tests for patients with two or more Centor criteria. Even patients with all the criteria described by Centor et al. – the four criteria – have a probability of streptococcal infection ranging from 39 to 57%. However, the adherence of Spanish GPs to these recommendations is very poor, since only one out of ten clinicians use the point-of-care tests to better identify the GAS in their consultations.

One of the limitations of GPs not using rapid tests is the uncertainty of the aetiological agent and this can lead to antibiotic overprescribing. The choice of empiric antimicrobial chemotherapy is guided in these cases by the clinical presentation, the severity of the infection, and epidemiologic data, comprising the causative organisms and their susceptibility to antimicrobial agents. However, GPs usually overestimate the incidence of streptococcal infection when the management is only based on clinical grounds. Due to the severity of these infections and the difficulties in determining the streptococcal aetiology, treatment is often empirical, usually consisting of orally administered agents.

According to the results obtained in this study two great areas of improvement arise: first, the use of antibiotics for otherwise suspected viral sore throat is considerable, as nearly one in five clinicians declared treating these patients unnecessarily. Second, there is also room for improvement regarding the choice of antibiotics in suspected or confirmed cases of streptococcal infection, since only 12% of the respondents stated that they would treat these infections with penicillin V. We found that more than nearly one third of the GPs preferred the prescription of a broad-spectrum β-lactam, such as amoxicillin and clavulanate. However, GAS is highly susceptible to penicillin (strains with a minimum inhibitory concentration >0.12 μg/mL have not been found) and should be considered susceptible to all β-lactams [29]. In some regions of the world, streptococcal resistance to antibiotics such as macrolides, clindamycin, and lincosamide has become an increasing concern [30, 31]. In other studies carried out in Spain, the use of antibiotics other than penicillin V, have ranked first in pharyngitis, with amoxicillin being the leading antibiotic used, as in our study [32, 33]. However, in an older study, amoxicillin and clavulanate was the preferred antibiotic by Spanish GPs [34].

Another issue to be highlighted in this study is the use of treatments other than antibiotics for patients with sore throat. Both oral analgesics and non-steroidal anti-inflammatory drugs were recommended by more than half of the respondents. Guidelines do not usually specify what drug is recommended and neither does the dose of these drugs suggested. However, most of the GPs stated to use usual doses of non-steroidal anti-inflammatory drugs and this has been shown to be associated with a higher risk for gastrointestinal disturbances [35]. It is also curious to observe that GPs are more prone to prescribe other drugs, such as decongestants, antitussives, expectorants and herbal remedies, when the infection is highly likely to be caused by a virus, a feature that has not been observed in other publications. These drugs are only available over-the-counter and have not shown to be effective. However, some clinicians might feel forced to give or recommend some products, mainly when an antibiotic is not prescribed.