Documentation and Management of Fever and Sore Throat in the Emergency Room
For patients presenting with fever and sore throat in the emergency room, a structured approach using clinical scoring systems followed by appropriate testing should be implemented to guide diagnosis and treatment decisions.
Initial Assessment and Documentation
Clinical Scoring System
- Use the Centor criteria to assess likelihood of Group A Streptococcal (GAS) infection 1:
- Fever history (temperature >38°C)
- Absence of cough
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
Essential Documentation Elements
- Vital signs: Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation
- Symptom duration and severity
- Associated symptoms:
- Presence of cough (suggests viral etiology)
- Difficulty swallowing
- Voice changes
- Respiratory distress
- Physical examination findings:
- Oropharyngeal appearance (erythema, exudates, petechiae)
- Cervical lymphadenopathy
- Rash (if present)
- Respiratory examination
COVID-19 Screening
- During pandemic periods, screen all patients with fever and sore throat for COVID-19 infection 1
- Perform RT-PCR nasopharyngeal swab testing for patients with suspected COVID-19
- Consider chest imaging based on respiratory symptoms and local protocols
Diagnostic Testing
Based on Centor Score
- 0-1 Centor criteria: No testing or antibiotics needed 1, 2
- 2-3 Centor criteria: Perform rapid antigen detection test (RADT) 1, 2
- 4 Centor criteria: Consider empiric treatment or testing based on clinical judgment 1
Testing Protocol
- Rapid antigen detection test (RADT) is recommended as first-line test 1
- For children and adolescents with negative RADT, perform throat culture 1, 2
- For adults with negative RADT, additional throat culture is not necessary 1
- Testing is generally not recommended in children younger than 3 years unless there are specific risk factors 1
Treatment Plan
Antibiotic Selection
If GAS pharyngitis is confirmed:
First-line treatment: Penicillin V for 10 days 1, 2
- Children: 250 mg 2-3 times daily
- Adolescents/adults: 250 mg 4 times daily or 500 mg twice daily
Alternative first-line: Amoxicillin for 10 days 1, 2
- 50 mg/kg once daily (maximum 1,000 mg)
- OR 25 mg/kg twice daily (maximum 500 mg per dose)
For penicillin-allergic patients 1, 2:
- Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days (if no anaphylactic reaction)
- Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days
- Azithromycin or clarithromycin (with caution due to variable resistance patterns)
Symptomatic Treatment
- Ibuprofen or paracetamol for pain and fever relief 1
- Avoid aspirin in children due to risk of Reye syndrome 1
- Corticosteroids are not routinely recommended 1
Special Considerations
When to Consider Broader Differential Diagnosis
- Severe symptoms or toxic appearance
- Inability to swallow or respiratory distress
- Asymmetric findings or peritonsillar abscess
- Immunocompromised status
- Failure to improve with appropriate therapy
Follow-up Recommendations
- No routine post-treatment testing is needed for asymptomatic patients 1
- Patients should be advised to return if symptoms worsen or fail to improve within 48-72 hours of antibiotic initiation
- Patients with recurrent episodes may need evaluation for chronic carrier state or consideration of tonsillectomy 2
Common Pitfalls to Avoid
- Overdiagnosis and unnecessary antibiotic prescription (only 5-15% of adult sore throats are caused by GAS) 3
- Failure to consider COVID-19 during pandemic periods 1
- Inappropriate use of broad-spectrum antibiotics when narrow-spectrum options are appropriate 2
- Inadequate duration of antibiotic therapy (full 10-day course is recommended to prevent complications) 1, 2
- Failure to recognize potential complications like peritonsillar abscess or rare sequelae like pulmonary-renal syndrome 4
By following this structured approach to documentation and management, emergency physicians can efficiently diagnose and treat patients with fever and sore throat while avoiding unnecessary antibiotic use and ensuring appropriate follow-up.