What is the recommended treatment for a sore throat?

Recommended Treatment for Sore Throat

For acute sore throat, either ibuprofen or paracetamol are recommended as first-line treatment for symptom relief, with antibiotics reserved only for cases with high likelihood of streptococcal infection (3-4 Centor criteria). 1

Diagnostic Approach

Before determining treatment, assess the severity using the Centor criteria:

• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Fever >38°C
• Absence of cough

Risk Stratification:

• 0-2 Centor criteria: Low risk of streptococcal infection
• 3-4 Centor criteria: Higher risk of streptococcal infection

For patients with 3-4 Centor criteria, consider using a rapid antigen test (RAT) to confirm streptococcal infection 1. A negative RAT eliminates the need for throat culture.

Treatment Algorithm

1. Symptomatic Treatment (First-Line)

• Analgesics/Anti-inflammatory medications:
  • Ibuprofen (recommended) 1, 2, 3
  • Paracetamol/acetaminophen (recommended) 1

Evidence suggests ibuprofen may have a better benefit-risk profile compared to acetaminophen for sore throat pain 2, 3. A direct comparison study showed ibuprofen 400mg was more effective than acetaminophen 1000mg for sore throat pain relief 2.

2. Antibiotic Treatment

Antibiotics should NOT be used in patients with less severe presentation (0-2 Centor criteria) 1, 4

For patients with 3-4 Centor criteria:

• First choice: Penicillin V, twice or three times daily for 10 days 1, 4
• Alternative for penicillin-allergic patients: Clarithromycin 4

While azithromycin has shown clinical efficacy in pharyngitis/tonsillitis due to Group A streptococci 5, penicillin V remains the recommended first-line antibiotic treatment according to guidelines 1.

3. Other Treatments

• Corticosteroids: Not routinely recommended but can be considered in adult patients with severe presentations (3-4 Centor criteria) in conjunction with antibiotic therapy 1
• Zinc gluconate: Not recommended due to conflicting results and increased adverse effects 1
• Herbal treatments and acupuncture: Inconsistent evidence for efficacy 1
• Local anesthetics: Can be considered for symptomatic relief (lidocaine, benzocaine, or ambroxol) 3

Important Considerations and Pitfalls

1. Overuse of antibiotics: Most sore throats are viral in origin and self-limiting, with a mean duration of 7 days 4. Unnecessary antibiotic use contributes to antimicrobial resistance, affects gut microbiota, and increases healthcare costs 1.

2. Prevention of complications: The prevention of suppurative complications is not a specific indication for antibiotic therapy in sore throat in modern healthcare settings 1.

3. Patient education: Inform patients about the self-limiting nature of most sore throats and involve them in decision-making regarding antibiotic use 6.

4. Red flags requiring urgent attention:

   • Immunosuppression
   • Severe comorbidity
   • Signs of severe systemic infection
   • Difficulty breathing or swallowing
   • Significant voice changes

5. Treatment duration: Current evidence does not support shorter antibiotic treatment courses than the recommended 10 days for penicillin V 1, though some newer guidelines suggest 5-7 days may be sufficient 4.

By following this evidence-based approach, most patients with sore throat can be effectively managed with symptomatic treatment alone, reserving antibiotics for those with clear indications of bacterial infection.