Should chemists be allowed to give antibiotics without a GP prescription?

UNDER new NHS plans, people with sore throats are being encouraged to visit their pharmacist instead of their Gp for an on-the-spot test to see if they need antibiotics. But will it make any difference to patients’ symptoms?

The new walk-in Sore Throat Test and Treat Service offers patients a five-minute test which determines whether their illness is caused by a virus — which antibiotics won’t help — or by bacteria, which do respond to the treatment.

If they test positive for a bacterial infection, pharmacists will be able to prescribe them antibiotics.

NHS england says the ‘evidence-based and cost-saving’ initiative could reduce the 1.2 million Gp appointments a year for sore throats by two-thirds, saving £34 million a year.

A pilot study suggests it could prevent unnecessary prescribing of antibiotics which can lead to superbugs becoming resistant to drugs — currently six in ten sore throat patients are prescribed antibiotics, according to a study published in 2014 in the Journal of Antimicrobial Chemotherapy, while the pilot study gave them to only one in ten.

Yet there are many unanswered questions. First, is this the right test to check sore throats? The scheme uses a swab test, which shows whether bugs that cause bacterial infections in the throat — group A streptococci — are present by measuring sugars on the tongue.

However, research by Southampton University found that these tests — known as rapid antigen tests — are no better at predicting which patients need antibiotics than a clinical ‘score’ (based on factors such as whether the patient has a temperature, how long they have had symptoms, and whether they have pus on their tonsils).

The three-year trial, published in the British Medical Journal in 2013, which involved 1,760 Gp patients, concluded that the rapid antigen tests provided ‘ no clear advantages’.

paul Little, a professor of primary care research at Southampton University who led the study, says: ‘ In fact, using a clinical score resulted in better symptom control than when using a rapid test.’

The second question is whether the scheme has been adequately tested. It was trialled in 35 Boots pharmacies over seven months. Just 367 people took part and the results, published in the Journal of Antimicrobial Chemotherapy, were not compared with usual care, so there is no way of knowing whether more or fewer antibiotics were prescribed.

Yet NHS chief executive Simon Stevens has announced plans to roll out the scheme over the coming year — it is not clear who will fund it or whether patients will have to pay for it (in the pilot, patients paid £ 7.50 for the test and £ 10 for antibiotics if required).

The third question is are pharma- cists the right people to be diagnosing patients with sore throats which can develop into serious problems such as sepsis or rheumatic fever?

pharmacists offering this new service would be trained in how to spot warning signs of complications and would only prescribe antibiotics under strict guidelines.

However, pharmacists don’t currently have access to patients’ medical records so would have to rely on patients advising them if they have any allergies or other medical conditions ( patient records will be available to pharmacists in the next 12 months, according to the Royal pharmaceutical Society). But will the scheme actually reduce antibiotic use? All 36 patients who tested positive for group A streptococci in the pilot were given antibiotics.

Yet Dr Christoffer Van Tulleken, a virologist at University College Hospital and a TV presenter, says not everyone with a positive test needs antibiotics.

THEswabs cannot differentiate between infection and just having the bugs harmlessly in the throat, he says — between 5 and 40 per cent of people carry the bugs, depending on the study cited.

‘Many people have streptococci bugs in their throat, but if they have a sore throat and no fever, they are not clinically ill and may not need antibiotics,’ he says.

‘There is little evidence that the swabs make any impact on prescribing decisions and may end up leading to more not less antibiotics.’

In his show The Doctor Who Gave Up Drugs, Dr Van Tulleken tested a similar machine that checks for signs of all bacterial infections, not just throat infections. He said it was ‘useful for reassuring patients’ but at £5 a blood test, it was expensive.

‘The concern about prescribing under strict protocols, as pharmacists would be doing, is that everyone who tests positive will be given antibiotics when they might not be necessary.’

professor paul Little fears that introducing the test could ‘medicalise normal life’.

‘Offering this in pharmacies will potentially encourage people with milder illness that could be managed without antibiotics, to get treatment they do not need,’ he says.

‘Taking antibiotics for a sore throat is not necessary for most people and studies show it reduces the length of illness by about one day.’