From the Guidelines
A sore throat workup should begin with a thorough history and physical examination to determine the likely cause, and antibiotics should only be considered in patients with confirmed strep throat or a high likelihood of group A streptococcal infection, as indicated by 3-4 Centor criteria 1. The most recent and highest quality study, published in 2016, recommends that clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis by rapid antigen detection test and/or culture for group A Streptococcus, and treat patients with antibiotics only if they have confirmed streptococcal pharyngitis 1. For viral pharyngitis, which accounts for most cases, symptomatic treatment with acetaminophen (500-1000mg every 6 hours) or ibuprofen (400-600mg every 6-8 hours), warm salt water gargles, and adequate hydration is sufficient 1. If strep throat is suspected, a rapid strep test or throat culture should be performed, and for confirmed strep throat, penicillin V (500mg twice daily for 10 days) is the first-line treatment, with amoxicillin (500mg twice daily for 10 days) as an alternative 1. Some key points to consider in the workup and treatment of sore throat include:
- The use of the Centor scoring system to identify patients with a high likelihood of group A streptococcal infection 1
- The importance of distinguishing between viral and bacterial causes of sore throat to avoid unnecessary antibiotic use 1
- The recommendation for penicillin V as the first-line treatment for confirmed strep throat, with amoxicillin as an alternative 1
- The consideration of azithromycin or clindamycin for penicillin-allergic patients 1
- The need for further investigation with laryngoscopy in cases of persistent sore throat lasting more than 2 weeks, associated with hoarseness, difficulty swallowing, or unilateral symptoms 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Sore Throat Workup
- A sore throat is a common reason for consultation of family physicians, usually triggered by infections of the pharynx 2.
- The causative organisms of sore throat may be bacteria (most commonly Streptococcus) or viruses (typically rhinovirus), although it is difficult to distinguish bacterial from viral infections clinically 3.
- Clinical decision rules, such as the Centor score, can be used to assess the risk of group A beta-hemolytic streptococcal infection 4, 5.
- Available diagnostic tests include throat culture and rapid antigen detection testing, with throat culture considered the diagnostic standard 5.
- The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 5.
Treatment Options
- Penicillin and amoxicillin are first-line antibiotics, with a recommended course of 10 days 5, 6.
- First-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 5, 6.
- Steroids are not recommended for symptomatic treatment 6.
- Ibuprofen and naproxen are recommended for symptomatic treatment 2.
- Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment should be reevaluated 6.
Management Strategies
- No testing and no treatment is preferred for patients with low risk of group A beta-hemolytic streptococcal infection 4.
- Rapid strep test with culture of negative results is the best management strategy for patients with high risk of group A beta-hemolytic streptococcal infection 4.
- Tonsillectomy is rarely recommended as a preventive measure, with specific thresholds for considering surgery 6.