The Fever PAIN score was derived from a cohort study including 1760 adults and children aged 3 and over. The score was tested in a trial comparing three prescribing strategies, empirical delayed prescribing, use of the score to direct prescribing or combination of the score with use of a near patient test (NPT) for streptococcus. Using the score resulted in more rapid symptom resolution and reduced prescribing of antibiotics (both reduced by one third). The addition of the NPT did not confer any additional benefit.

• Fever during previous 24 hours;
• Purulence;
• Attend rapidly (<=3 days);
• very Inflamed tonsils;
• No cough/coryza (FeverPAIN)

Using the sore throat tool enables rapid calculation of the score, gives a treatment guide and provides a summary to cut and paste in the notes.

Published papers:

1. Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Delaney B, et al. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis. 2014.
2. Little P, Hobbs FR, Moore M, Mant D, Williamson I, McNulty C, et al. PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess. 2014;18(6):1-102.
   http://eprints.soton.ac.uk/361649/
3. Little P, Moore M, Hobbs FD, Mant D, McNulty C, Williamson I, et al. PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A beta-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open. 2013;3(10):e003943.

Delayed prescribing does not simply mean the issue of a prescription with vague wording about delay but should include:

1. Information on the natural history of the illness

   ‘Sore throats typically last 7-10 days in total but you should start to feel better after about the 5th day’

2. Information about the benefit of antibiotics

   ‘Antibiotics on average reduce the duration of symptoms by about 12 hours’

3. Then summarise

   ‘Sore throats will get better on their own if you leave your body to fight off the bugs and antibiotics are of limited help. Some people find it useful to have an antibiotic prescription to cash in if the symptoms are getting worse or not improving as expected- would you be interested in this’

4. An explanation of the delay, the precise delay will depend on the severity of the illness and how long the symptoms have been present already but be explicit and be prepared to negotiate

   ‘You have already been ill for 3 days so I would expect you to start to improve within a couple of days, if you are not improving after 5 days then cash in the prescription’

5. Summarise and safety net

   ‘So in summary then we would expect this illness to last 6-10 days on average and antibiotics are unlikely to have much effect on this. I have given you a prescription and you are in charge of when to take this. I suggest you wait about 5 days before cashing in the prescription but of course if you get much worse in the meantime you can cash it in earlier or get back in touch with me’

A patient hand out to aid delayed prescribing is available on the RCGP Target website

To copy all the summary information to the clipboard:

• Click in the summary text box
• Ctrl+A or R-Mouse > Select all
• Ctrl+C or R-Mouse > Copy

• Select destination
• Ctrl+V or R-Mouse > Paste

To create a desktop shortcut to this site:

• Simply drag the icon from the browser address box to the desktop

• R-Mouse click on your Desktop and select New > Shortcut
• For the location use: https://ctu1.phc.ox.ac.uk/feverpain
• Click <Next>
• For the shortcut name use: FeverPAIN Clinical Score
• Click <Finish>