• Paul Little, Beth Stuart, Zoe Wingrove, Mark Mullee, Tammy Thomas, Sophie Johnson, Gerry Leydon, Samantha Richards-Hall, Ian Williamson, Lily Yao, Shihua Zhu, and Michael Moore.
• Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK P.Little@soton.ac.uk.
• CMAJ. 2017 Dec 18; 189 (50): E1543-E1550.

BackgroundReducing the use of antibiotics for upper respiratory tract infections is needed to limit the global threat of antibiotic resistance. We estimated the effectiveness of probiotics and xylitol for the management of pharyngitis.MethodsIn this parallel-group factorial randomized controlled trial, participants in primary care (aged 3 years or older) with pharyngitis underwent randomization by nurses who provided sequential intervention packs. Pack contents for 3 kinds of material and advice were previously determined by computer-generated random numbers: no chewing gum, xylitol-based chewing gum (15% xylitol; 5 pieces daily) and sorbitol gum (5 pieces daily). Half of each group were also randomly assigned to receive either probiotic capsules (containing 24 × 109 colony-forming units of lactobacilli and bifidobacteria) or placebo. The primary outcome was mean self-reported severity of sore throat and difficulty swallowing (scale 0-6) in the first 3 days. We used multiple imputation to avoid the assumption that data were missing completely at random.ResultsA total of 1009 individuals consented, 934 completed the baseline assessment, and 689 provided complete data for the primary outcome. Probiotics were not effective in reducing the severity of symptoms: mean severity scores 2.75 with no probiotic and 2.78 with probiotic (adjusted difference -0.001, 95% confidence interval [CI] -0.24 to 0.24). Chewing gum was also ineffective: mean severity scores 2.73 without gum, 2.72 with sorbitol gum (adjusted difference 0.07, 95% CI -0.23 to 0.37) and 2.73 with xylitol gum (adjusted difference 0.01, 95% CI -0.29 to 0.30). None of the secondary outcomes differed significantly between groups, and no harms were reported.InterpretationNeither probiotics nor advice to chew xylitol-based chewing gum was effective for managing pharyngitis. Trial registration: ISRCTN, no. ISRCTN51472596.© 2017 Joule Inc. or its licensors.

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