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To prescribe or not to prescribe for paediatric sore throat: a retrospective cohort study comparing clinician-led antibiotic prescriptions to FeverPAIN and Centor scoring in a tertiary paediatric emergency department and a national review of practice
  1. Michael Malley1,
  2. Katie Driver2,
  3. Megan Costelloe2,
  4. Isla Monaghan2,
  5. Lucy Jefferson3,
  6. Louise Poole3,
  7. Cliona Lewis3,
  8. Rachael Salt3,
  9. Robin Marlow1,4
  1. 1 Paediatric Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
  2. 2 Medical School, University of Bristol, Bristol, Avon, UK
  3. 3 Paediatrics, Bristol Royal Hospital for Children, Bristol, Bristol, UK
  4. 4 Population Health Sciences, University of Bristol, Bristol, UK
  1. Correspondence to Dr Michael Malley, Paediatrics, Chelsea and Westminster Hospital NHS Foundation Trust, London TW7 6AF, UK; michaelkmalley{at}


Background Tonsillopharyngitis is a common presentation to paediatric emergency departments (PEDs). FeverPAIN (FP) and Centor scoring systems are recommended in the UK to help delineate bacterial aetiology, despite being primarily evidenced in adult populations. We investigate how the use of FP or Centor compares to actual clinician practice in guiding antibiotic prescription rates in PED. We establish current national practice in English PEDs.

Methods We performed a retrospective cohort study of tonsillopharyngitis presentations to a tertiary PED in January–February 2020. Investigators retrospectively assigned each patient FP and Centor scores using documented symptoms. We compared antibiotic prescription rates guided by FP/Centor against the actual rate prescribed by clinicians, and assessed agreement between these strategies using kappa analysis. We contacted 153 English emergency departments to establish national practice.

Results We identified 632 consecutive patients aged 6 months to 15 years. Actual clinician-prescribed antibiotics numbered 116 (18.4%). Prescriptions predicted by FP score numbered 124 (19.6%) and Centor 112 (17.7%). Kappa (K) analysis indicated only moderate agreement between clinician choice versus FP (K=0.434) and clinician choice versus Centor (K=0.476). This was similar for cohorts aged under and over 3 years.

National practice was reportedly heterogeneous, with 70 emergency departments (45.8%) not employing a specific system.

Conclusion Current guidance is variably interpreted and inconsistently implemented in paediatric populations. FeverPAIN and Centor scoring systems may not rationalise antibiotics as much as previously reported compared with judicious clinician practice. Producing clear paediatric-specific national guidelines, especially for under-5s who are omitted from NICE sore throat guidance, may help further rationalise and standardise antibiotic use in paediatric tonsillopharyngitis.

  • bacterial
  • emergency department
  • ENT
  • guidelines
  • paediatrics
  • paediatric emergency medicine

Data availability statement

Data are available on reasonable request from the corresponding author.

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Data availability statement

Data are available on reasonable request from the corresponding author.

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  • Handling editor Gene Yong-Kwang Ong

  • Contributors MM, KD, IM and MC were involved in all aspects of this study from beginning to end. CL, LP and RS performed national survey. LJ and LP undertook literature searches and helped draft the article. RM supervised throughout and edited the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.