1 Recommendations

1 Recommendations

This guidance covers using rapid tests for group A streptococcal (strep A) infections in people aged 5 and over with a sore throat.

For children under 5, assessment is described in NICE's guideline on fever in under 5s: assessment and initial management.

People who are at higher risk of complications, for example women who are pregnant or who have just had a baby, or people who are immunocompromised, should be offered antibiotics in line with NICE's guideline on antimicrobial prescribing for acute sore throat.

This guidance also does not cover using the rapid tests:

  • for people presenting with scarlet fever. Scarlet fever is a notifiable condition; its diagnosis and management is covered in guidance from Public Health England

  • to help manage outbreaks of strep A infections because this is different to using the tests for people presenting to healthcare providers with an uncomplicated sore throat.

1.1 Rapid tests for strep A infections are not recommended for routine adoption for people with a sore throat. This is because their effect on improving antimicrobial prescribing and stewardship, and on patient outcomes, as compared with clinical scoring tools alone, is likely to be limited. Therefore, they are unlikely to be a cost-effective use of NHS resources.

Why the committee made these recommendations

Unnecessary use of antibiotics can contribute to antimicrobial resistance, which is a public health concern. NICE's guideline on antimicrobial prescribing for acute sore throat aims to limit antibiotic use and reduce antimicrobial resistance. It advises that sore throat is self-limiting and so, in people who are otherwise healthy, antibiotics are usually not needed regardless of the cause (bacterial or viral). So, it is uncertain whether there is a clinical need for rapid testing for strep A infections in the people covered by this guidance. Also, the diagnostic accuracy of the tests in routine clinical practice is uncertain and likely to be highly variable. There is no evidence to suggest that using the rapid tests could reduce antibiotic prescribing or improve clinical outcomes for people with a sore throat, as compared with clinical scoring tools alone.

The economic modelling predicts a reduction in antibiotic use with the rapid tests, but this is based on uncertain evidence, and it is therefore unclear if it would be replicated in NHS practice. The introduction of the guideline on antimicrobial prescribing for acute sore throat may, on its own, substantially reduce antibiotic prescribing. There is also uncertainty about whether confirming a bacterial infection by rapid testing could lead to changes in patient and clinical behaviour that result in increased antibiotic prescribing when antibiotics would not usually be prescribed.

The predicted reduction in antibiotic use is included in the cost-effectiveness analyses for using rapid tests in people with a sore throat but the resulting incremental cost-effectiveness ratios (ICERs) are much higher than what NICE usually considers acceptable. There is no evidence on the wider benefits of using the tests on antimicrobial stewardship and onward transmission rates. So these potential benefits are not considered in the modelling. However, it is unlikely that the effect of capturing these wider benefits would reduce the ICERs to the extent that these tests would be considered a cost-effective use of NHS resources. The uncertainty and likely minimal effect the rapid tests would have on reducing antibiotic use also means that there are likely to be limited or no wider benefits. Therefore, the rapid tests are not recommended.

  • National Institute for Health and Care Excellence (NICE)