Wrong treatment of sore throats is fuelling antimicrobial resistance

The Star

a day ago

In Malaysia, as in many other countries worldwide, there is a growing concern over a silent, yet widespread epidemic caused by the excessive and often inappropriate use of antibiotics.
This issue is particularly evident in the treatment of sore throats, which are usually the result of viral infections and do not require antibiotics.
Despite this, overprescription remains alarmingly high, especially in primary care settings.
Over the past decade, Malaysia has witnessed persistent and concerning patterns in the misuse of antibiotics for sore throats.
A 2022 study in public primary care clinics found that only 2.8% of sore throat cases were caused by group A Streptococcus – the only common bacterial cause warranting antibiotics.
Yet, antibiotics were prescribed to 22.3% of patients, with over 90% of those prescriptions being unnecessary.
In private clinics, the situation is even more pronounced: only 42.9% of prescriptions for sore throats were appropriate, while 58.5% were excessive.
On the rise again
The Health Ministry has consistently raised alarms about the escalating issue of antimicrobial resistance (AMR), yet the trend of overprescribing antibiotics remains prevalent due to several key factors: Patient misconceptions A 2021 study in the journal Patient Preference and Adherence showed that 79.1% of Malaysians mistakenly believe antibiotics can cure viral infections, and 77% mistakenly believe they can cure coughs and colds.
Doctor practices
Many physicians in both public and private primary care settings are often influenced by patient expectations and diagnostic uncertainty, leading to the prescription of antibiotics even when they are not clinically indicated.
Although antibiotic use temporarily declined during the Covid-19 pandemic due to heightened public health awareness, usage rates have since rebounded, particularly in the private sector.
In 2021, antibiotic utilisation in private primary care was nearly ten times higher than in public clinics.
The misuse of antibiotics contributes directly to the rise of antibiotic-resistant superbugs, which pose a significant threat to public health.
A 2021 study from a Malaysian tertiary hospital, published in the journal Pathogens , identified high rates of beta-lactam resistance among common respiratory pathogens such as Streptococcus pneumoniae and Haemophilus influenzae .
These pathogens, once easily treatable, now present serious challenges to effective treatment due to resistance.
Community-acquired infections with methicillin-resistant Staphylococcus aureus (MRSA) are also becoming more common.
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A clinical consensus
Group A Streptococcus bacteria (orange), seen here in a colourised scanning electron microscope image, are the only common cause of sore throats that warrant the use of antibiotics. — NIAID
The World Health Organization's Global Antimicrobial Resistance and Use Surveillance System (GLASS) has categorised Malaysia as a high-alert nation due to the increasing threat of AMR.
In comparison to other Asian countries, Malaysia is among the leading nations in terms of antibiotic overuse.
To address this, the 2024 Malaysian Sore Throat Consensus – formulated and finalised in 2023 – is set to be officially launched on July 22 (2025).
Developed through collaboration by a multidisciplinary panel of Malaysian experts, the consensus reflects updated evidence and local context, offering a unified, evidence-based approach to managing sore throats.
Contributors included representatives from primary care, otorhinolaryngology (ear, nose and throat, or ENT), paediatrics, microbiology and infectious diseases, respiratory medicine, pharmacy, and general practice, spanning both public and private sectors.
The consensus outlines several key clinical criteria and tools to guide appropriate diagnosis and management, including:
Antibiotics should not be the first-line treatment unless group A Streptococcus infection is confirmed.
Overprescription drives AMR. > Use of the McIsaac Score (Modified Centor Score)
This is a validated scoring system assessing bacterial likelihood based on symptoms such as fever, lymph node swelling and absence of cough.
A score of two or less suggests viral infection, while a score of three or less increases the likelihood of group A Streptococcus infection.
Rapid antigen detection tests for group A Streptococcus improve diagnostic certainty and reduce unnecessary antibiotic prescriptions.
Non-steroidal anti-inflammatory drugs (NSAIDs) like flurbiprofen lozenges or sprays, are recommended for pain relief, addressing patient needs without resorting to antibiotics. > Multidisciplinary approach
Developed by a panel with broad clinical representation, the consensus ensures relevance and applicability across Malaysia's diverse healthcare settings.
A stubborn problem
Despite ongoing awareness efforts, misconceptions and behavioural gaps remain entrenched.
Many patients continue to pressure clinicians into prescribing antibiotics and incomplete courses of antibiotics are still common.
National surveys confirm that public understanding remains low, highlighting the urgent need for continuous education campaigns and for healthcare professionals to serve as active educators.
AMR also brings severe economic and environmental consequences.
By 2050, the World Bank estimates that AMR could shrink the global economy by up to 3.8% and push 28 million people into poverty.
Treating resistant infections is up to three times more expensive than treating non-resistant ones.
Overprescribed antibiotics frequently end up in wastewater, contaminating soil and rivers, and accelerating the spread of resistance in the environment.
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Malaysia has already made significant strides, such as implementing stewardship programmes and launching public campaigns, but urgent, bolder steps are needed.
One practical and meaningful move within the next one to three years would be to strengthen antibiotic stewardship policies in primary care, particularly for upper respiratory tract infections.
This could include making clinical scoring tools or rapid antigen tests mandatory before antibiotics are prescribed and encouraging voluntary benchmarking of prescribing rates in clinics.
This approach promotes accountability without public shaming, while supporting clinicians in prescribing more wisely.
Looking ahead, the launch of the Malaysian Sore Throat Consensus represents a timely and critical step forward.
Grounded in local data and international best practices, this national initiative, supported by British multinational health and hygiene consumer goods company Reckitt, aims to empower frontline providers with the tools, clarity and confidence to combat antibiotic misuse effectively.
With firm, but supportive policies, cross-sector collaboration and consistent public education, Malaysia has the potential not only to safeguard public health domestically, but to also lead Asean in combating AMR on a regional scale.
Professor Dr Baharudin Abdullah is a senior consultant otorhinolaryngologist and head and neck surgeon at Universiti Sains Malaysia. For more information, email [e-mail]. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.