1. Journal Club 25 March 2015 Once daily amoxicillin vs Twice daily penicillin in GABHS pharyngitis ADC Feb 2008

2. Completely random choice of paper Was looking at papers for an entirely different topic

3. Recent outbreak of scarlet fever in children in UK. Leading many children to be on 10 day courses of penicillin V qds Compliance likely to be poor What alternatives are viable

4. In pre-school children with strep throat (P) is there an effective alternative (C) to qds penicillin V for ten days (I) to prevent rheumatic fever (O) ?

5. Better PICO P – UK kids with sore throats/scarlet fever I – once daily amox C – qds pen V O – reduce rheumatic fever

6. Current local practice Clinical diagnosis No specific diagnostic criteria No throat swabs Everyone gets 10/7 Pen V No follow up

7. 2yr period, 5-12yr olds at sore throat clinic (already consented) Sore throat + temp, headache, nausea, abdo pain, dysphagia, abn throat, tender glands Excluded – scarlet rash!!, a’bs, allergy, ARhF, cardiac dis, EBV, immcomp, oncol, Throat swab done, read at 24 and 48 hours If GABHS positive (353) randomised on day 1 Penicillin bd (176)Amoxicillin od (177) Repeat swabs D3-6, D12-16, D 26-36 With clinical re-evaluation

8. Randomised non-inferiority trial Not blinded No second dose placebo in amoxil group used Main outcome of interest was swab positivity

9. Results Amoxicillin od V2 – 6.5% pos V3 – 13.9% pos V4 – 15.7% pos –(new= 5%) 6.2% d/c Pen V bd V2- 6.2% pos V3- 13.8% pos V4 – 13.8% pos –(new=2.5%) 4% d/c

10. <10% difference was set as non-inferiority limit with 95% CL Needed 155 evaluable subjects for 80% power Child with persistent symptoms and pos swabs at V3 and 4 were given 10/7 Pen V

11. Results Valid? Their pop is typical for them Swab positivity taken as a quasi-measure of rheumatic fever Assignment randomised All pts accounted for? Sub-selected school pop ?supporting evidence Diff numbers at each visit. ?value of visit 4

12. No blinding Groups similar at start Treated equally

13. Results Once daily amoxicillin no worse than bd penicillin V Inference is that it will be better adhered to.

14. Local influence Our population is not the same (lower risk for Rh fever) Our standard treatment is different By their dosing rationale od Amox (750mg) 10/7 costs £2.78. 250mg qds Pen V x 10/7 costs £5.18 Might represent significant cost savings

15. Systematic review – (Anales de Pediatrica. Nov 2011. French) OD amoxicillin is not inferior to other regimens

16. NICE CKS Do not routinely prescribe antibiotics for acute sore throat. –Antibiotics should not be prescribed to: Secure symptomatic relief. Prevent suppurative complications. Treat recurrent non-streptococcal sore throat. Prevent the development of rheumatic fever and acute glomerulonephritis. Prescribe an antibiotic for: –Those with features of marked systemic upset. –Those at increase risk of serious complications.