Associated risks and effectiveness of antibiotics
In France, the prescription of antibiotics for acute angina with a positive rapid diagnostic test (RDT) is based on the prevention of acute rheumatic fever (ARF) and local complications such as phlegmons. However, the risk of AAR is less than 1/100,000 angina cases in mainland France and mainly concerns children aged 5 to 15 years. Studies supporting the effectiveness of antibiotics to prevent RAA date from before 1960 and are of low methodological quality.
Local complications, such as phlegmons, are rare. A Cochrane meta-analysis indicates a reduction in the risk of phlegmon from 1% to 0.16% with antibiotic therapy, but this study is based on old and biased data. Consequently, European recommendations do not consider the prevention of local complications as a sufficient indication for antibiotic therapy.
Contagiousness and antibiotic resistance
Limiting the contagiousness of invasive group A streptococcal infections (IISGA) is often cited as an argument in favor of antibiotics. However, the evidence to support this argument is weak. Two studies suggest that the duration of bacterial carriage is reduced to 24-48 hours under antibiotic therapy, but without a control group for comparison. Another study showed that 72% of untreated patients were still carriers at two weeks compared to 32% of patients treated with penicillin for one week.
France has seen an increase in IISGA, with a mortality rate estimated at 20%. The incidence increased from 2.2/100,000 in 2003 to 4.4/100,000 in 2019. Barrier measures during the Covid-19 pandemic temporarily reduced this incidence, but an upsurge was observed in 2022.
In terms of individual benefits, antibiotic therapy reduces the intensity of sore throats on the third day of treatment but does not significantly improve fever. The risks of antibiotic resistance, particularly to multi-resistant enterobacteria after treatment with penicillin, are also a major concern.
International differences and recommendations
The Belgian and Scottish recommendations differ from those of France. These countries recommend not systematically identifying the bacterial or viral cause of uncomplicated tonsillitis and not prescribing antibiotics, except for patients at risk of serious forms. In Belgium, this approach did not lead to a notable increase in IISGA despite a reduction in antibiotic prescriptions.
In conclusion, the CNGE scientific council maintains that for angina without risk of serious form and with tolerable pain, treatment with analgesics without RDT or antibiotics is reasonable. A RDT and antibiotic therapy are justified only in cases of identified risks. It is essential to conduct new clinical trials to reassess the benefit/risk balance of antibiotics in angina and adapt recommendations accordingly.
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