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Strep Testing in Primary Care: If the Evidence Exists, Why Hasn’t Guidance Changed?

Sore throat is one of the most common presentations in primary care. It’s also one of the most debated.

Because behind a seemingly simple symptom lies a difficult clinical challenge:

Is this viral — or bacterial (Group A Strep)?

And that decision directly drives antibiotic use.

The current UK approach: clinical scoring, not testing

In England, guidance from NICE recommends using clinical scoring systems such as:

  • Centor
  • FeverPAIN

to guide antibiotic prescribing decisions

https://www.nice.org.uk/guidance/ng84/chapter/recommendations

These scores are designed to:

  • Estimate the likelihood of bacterial infection
  • Support antimicrobial stewardship
  • Reduce unnecessary antibiotic use

This is important — because:

  • Most sore throats are viral
  • Around 90% resolve within 7 days without antibiotics

https://bmjopenquality.bmj.com/content/6/1/u211706.w4738

The problem: clinical scoring isn’t that accurate

While scoring systems are practical, they are far from perfect.

Even at higher scores:

  • A Centor score ≥3 only corresponds to ~32–56% probability of streptococcal infection

 https://pmc.ncbi.nlm.nih.gov/articles/PMC9447300/

In other words:

Even when guidelines suggest antibiotics, many patients won’t actually have bacterial infection

And at lower scores:

Some bacterial infections will inevitably be missed.

Sore Throat

The scale of the issue

Sore throat isn’t a niche problem — it’s a major workload driver:

  • Around 100 consultations per 1,000 population annually in UK general practice

https://pmc.ncbi.nlm.nih.gov/articles/PMC12533547/

  • Historically, more than half of sore throat patients receive antibiotics

https://pmc.ncbi.nlm.nih.gov/articles/PMC12533547/

At the same time:

  • Antimicrobial resistance is a major global health threat

https://pmc.ncbi.nlm.nih.gov/articles/PMC12533547/

Why NICE takes this approach

NICE guidance is not ignoring diagnostics — it is prioritising antimicrobial stewardship.

Key assumptions include:

  • Most infections are self-limiting
  • Clinical scoring is “good enough”
  • Routine testing may:
    • Add cost
    • Delay treatment
    • Not significantly change outcomes at scale

There are also historical concerns around:

  • Lab-based testing delays (e.g. 24–48 hours for culture)

https://rightdecisions.scot.nhs.uk/ggc-primary-care/paediatrics/paediatrics-clinical-guidelines/throat-infections-emergency-medicine-paediatrics-336/

But the landscape is changing

This is where the tension emerges.

Because today:

  • Rapid point-of-care tests exist
  • Results can be delivered in minutes
  • Accuracy is significantly higher than clinical scoring

And evidence suggests:

Without testing, 20–38% of true strep cases may miss appropriate antibiotics

https://bmjopen.bmj.com/content/12/4/e059069

At the same time, many non-bacterial cases still receive antibiotics unnecessarily

A fragmented UK picture

Interestingly, not all UK nations are aligned:

  • Wales → Pharmacy First includes strep POCT
  • Northern Ireland → commissioned in community pharmacy
  • Scotland → moving in the same direction

Meanwhile:

England continues to follow NICE guidance

No widespread commissioning of POCT

So why hasn’t NICE changed?

The answer is likely not purely clinical — but structural.

NICE guidance prioritises:

  • Population-level cost-effectiveness
  • Simplicity and scalability
  • Reducing unnecessary antibiotic use

But typically requires:

  • Strong UK-specific evidence
  • Economic modelling
  • Demonstration of impact at scale

Until then:

Guidance tends to remain conservative

The real question: are we missing an opportunity?

The current system is designed to:

  • Reduce unnecessary antibiotics
  • Manage risk pragmatically

But it also accepts:

  • Diagnostic uncertainty
  • Over- and under-treatment

And that raises an important question:

If we now have tools that improve diagnostic accuracy in real time — should the pathway evolve?

Where point-of-care testing fits

Point-of-care testing doesn’t replace clinical judgement.

But it changes the nature of the decision:

Instead of Estimating probability

It enables Confirming infection

Which can:

  • Reduce unnecessary antibiotic use
  • Ensure true bacterial cases are treated
  • Support clearer patient communication

Final thought

Sore throat management has always been about balance:

  • Risk vs reassurance
  • Treatment vs restraint

NICE guidance reflects that balance — but it was built around the tools available at the time.

The question now is:

Has the evidence changed — but the guidance hasn’t yet caught up?