Shared decision making for suspected streptococcal pharyngitis and tonsillitis in patients not at high risk of acute rheumatic fever

To engage in shared decision making with patients and carers:

• Reassure the patient or carer that streptococcal pharyngitis and tonsillitis are usually self-limiting. Some patient groups are at high risk of acute rheumatic fever.
• Ask about the patient or carer’s expectations for management of streptococcal pharyngitis and tonsillitis.
• Explain that there are two treatment approaches:
  • Symptomatic therapy alone with follow-up if symptoms do not improve within a reasonable timeframe (eg 3 to 7 days), or if symptoms worsen or new symptoms develop (eg vomiting, dehydration, rigors) at any time. A delayed prescription for antibiotic therapy can be offered if the patient will not be able to returnSpurling, 2017.
  • Symptomatic therapy plus an immediate prescription for antibiotic therapy.
• Explain that symptoms of streptococcal pharyngitis and tonsillitis usually last 7 days, whether or not antibiotics are used.
• Discuss the limited benefits of antibiotic therapy, even when a bacterial cause is likely.
  • Antibiotics only shorten the duration of symptoms by less than 1 daySpinks, 2013.
  • Antibiotics can prevent acute rheumatic fever, but this is a rare complication of streptococcal infection in patients who are not in a high-risk group.
• Discuss the potential harms of antibiotic therapy.
  • Adverse effects of antibiotics include diarrhoea, rash or more serious hypersensitivity reactions.
  • Antibiotics disrupt the balance of bacteria in the body (the microbiome). While the consequences of this are not fully understood, it can cause problems ranging from yeast infections (eg thrush) to more serious infections (eg Clostridioides difficile [formerly known as Clostridium difficile] infection).
  • Antibiotics can cause bacteria in the body to become resistant to antibiotics so that future infections are harder to treat. Multidrug-resistant bacteria (known as ‘superbugs’) can be spread between people, affecting other family members and the community.
• Ask about the preferences, values and concerns of the patient or carer, and answer any remaining questions.
• Make a joint decision about whether to use symptomatic therapy alone or combine symptomatic therapy with antibiotic therapy [NB1] [NB2]; if a decision is made to use antibiotic therapy, see Antibiotic therapy for streptococcal pharyngitis and tonsillitis for treatment recommendations.
• Discuss criteria for patient follow-up and reassessment. Ask the patient to return if symptoms (particularly fever) do not improve within a reasonable timeframe (eg 3 to 7 days), or if symptoms worsen or new symptoms develop (eg vomiting, dehydration, rigors) at any timeNational Institute for Clinical Excellence (NICE), 2018.