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There are a number of reasons behind differences in the supply of antibiotics but point-of-care testing appears to have reduced the rate. Steve Titmarsh reports…

A study suggesting that point of care testing may reduce the level of antibiotic prescribing for patients using the Pharmacy First scheme may raise questions or concerns in territories that do not include testing as part of their clinical pathway, not least in terms of implications for antibiotic stewardship.

A study by researchers from the London School of Hygiene & Tropical Medicine and Cardiff University found that patients with a sore throat were more than twice as likely to be given antibiotics by a pharmacist through England’s Pharmacy First scheme compared with a similar scheme in Wales.

The researchers looked at 317,864 acute sore throat Pharmacy First (ASTPF) and 27,684 sore throat test and treat (STTT) pharmacy consultations between 1 February 2024 and 30 July 2024, covering the first six months of ASTPF.

That represented 551.0 and 874.9 consultations per 100,000 population in England and Wales. The antibiotic supply rate was 72.7% for ASTPF and 29.9% for STTT. The researchers commented that ‘limiting analysis to consultations with FeverPAIN scores of 4 or more increased the prescribing rate in STTT to 59.7% but this remained significantly lower than the ASTPF at 72.7%’.

Reasons for differences in the supply of antibiotics

There could be a number of reasons for differences in the supply of antibiotics but point of care testing does seem to have contributed to the reduced rate seen in Wales.¹ Interestingly, an earlier study found that 21% of STTT consultations for sore throat in pharmacies in Wales led to the supply of an antibiotic compared with 39% of GP consultations.²

The Department of Health in Northern Ireland told the Independent Community Pharmacist that following a successful pilot service in the winter of 2023/24, the Pharmacy First sore throat service in Northern Ireland was introduced in over 400 community pharmacies across the region³ in December 2024 and since then more than 15,000 people have used the service.

Since roll-out of the service in December 2024 almost 27% of referrals have come from GPs and out of hours services, with 65% of people self-referring.

Based on the evaluation of the pilot service that was undertaken there has been some very positive service user feedback including comments such as:

‘Great service to avoid lengthy wait for GP’.

‘This service is needed for quick diagnosis and was a godsend. It will save the hospitals taking the weight of these illnesses that can be tested in minutes around the corner’.

‘[Pharmacy] was a really excellent. The pharmacist, was warm and approachable, and provided a comprehensive service. This approach is much better than using the GP/out of hours and I would love to see it rolled out to more pharmacies.’

The Department of Health added that feedback from GP stakeholders was also generally positive, including that patients had quicker access to advice and treatment, there was an option to do a swab to help confirm diagnosis, reducing inappropriate prescribing of antibiotics and there was an opportunity to provide patient education about self-care.

Latest analysis of prescribing data indicates that only 21% of consultations resulted in supply of an antibiotic, demonstrating excellent antimicrobial stewardship, the Department of Health told Independent Community Pharmacist.

We continue to monitor antibiotic prescribing rates

Asked whether the difference in antibiotic prescribing identified in the recent study by researchers from the London School of Hygiene & Tropical Medicine and Cardiff University raised any concerns or issues for the service in Northern Ireland, the Department of Health said: ‘We continue to monitor antibiotic prescribing rates for this, and other services, to ensure that the service meets the needs of the patients whilst mindful of the importance of broader antimicrobial stewardship objectives.’

Commenting on the implications of the recent study by researchers from the London School of Hygiene & Tropical Medicine and Cardiff University, Amandeep Doll, Royal Pharmaceutical Society director for England, told Independent Community Pharmacist that: ‘Ongoing evaluation of new services such as Pharmacy First is essential to ensure antibiotics are being used appropriately.

‘Differences in supply rates between England and Wales may reflect the early stage of the Pharmacy First rollout, variation in service design and patient behaviour, rather than inappropriate prescribing. Socio-demographic differences between patient populations in England and Wales attending pharmacies – such as levels of deprivation, health literacy and other contextual factors – may also play a role.

‘With clear guidance, ongoing training and feedback, pharmacists can continue to uphold strong antimicrobial stewardship and ensure antibiotics are only supplied when clinically necessary.’

Asked whether there is a sufficient level of awareness among community pharmacists about antibiotic resistance and its likely causes and prevention, Ms Doll said: ‘Pharmacists are experts in medicines and have long played a big role in antimicrobial stewardship by helping people to self-care and advising how to use antibiotics safely and effectively.

‘The clinical pathways for Pharmacy First were developed by medical experts groups and are designed to safeguard against unnecessary antibiotic use. Continued investment in training, clinical guidance and public education will help sustain good stewardship.

‘It’s also important that patients are honest about their symptoms so pharmacists can make accurate assessments, provide the most appropriate treatment and help to protect the effectiveness of antibiotics for the future.’

She went on to say that ‘point of care testing can help decision-making by confirming bacterial infection and helping reduce unnecessary antibiotic use.

‘However,’ she adds, ‘the Pharmacy First pathway in England already provides a robust framework, using the FeverPAIN score and professional assessment to guide appropriate supply. What matters most is that pharmacists are equipped with the right support and training to make informed decisions and continue their vital role in protecting the effectiveness of antibiotics’.

In October 2025 the Infectious Disease Society of America updated its Clinical Practice Guideline on Group A Streptococcal (GAS) pharyngitis. They suggested that a clinical scoring system should be used to determine which children and adults with sore throat should be tested for GAS. The recommendation was rated as conditional, with a very low certainty of evidence.

The Society noted: ‘Streptococcus pyogenes causes pharyngitis in up to 15% of adults and 30% of children with pharyngitis,’ explaining that ‘the principal utility of a scoring system is to identify patients with low probability of GAS pharyngitis, in whom further evaluation by diagnostic testing is unlikely to be helpful.’⁴

References

1. Matuluko A, Mantzourani E, Ahmed H, et al. Comparison of antibiotic provision associated with acute sore throat symptom management in community pharmacies in Wales and England: a natural policy experiment, Journal of Antimicrobial Chemotherapy 2025;80:1256–60.

2. Mantzourani E, Ahmed H, Bethel J, et al. Clinical outcomes following acute sore throat assessment at community pharmacy versus general practice: a retrospective, longitudinal, data linkage study. Journal of Antimicrobial Chemotherapy 2025;80:227–37.

3. Department of Health, Northern Ireland. Sore Throat Service rolled out across community pharmacies (www.health-ni.gov.uk/news/sore-throat-service-rolled-out-across-community-pharmacies-0; accessed November 2025).

4. Barshak MB, Watson Jr, ME, Wessels MR, et al. Clinical Practice Guideline Update by the Infectious Diseases Society of America on Group A Streptococcal (GAS) Pharyngitis (www.idsociety.org/practice-guideline/streptococcal-pharyngitis2; accessed November 2025).