What is the recommended treatment for a sore throat?

Treatment for Sore Throat

For acute sore throat, ibuprofen or paracetamol (acetaminophen) are recommended as first-line treatments for symptom relief, with antibiotics reserved only for cases with high likelihood of streptococcal infection (3-4 Centor criteria). 1, 2

Symptomatic Treatment

First-Line Analgesics

• Ibuprofen: 5-10 mg/kg every 6-8 hours for children; adult dose 400-600 mg every 6-8 hours
  • Shows slightly better efficacy as both an analgesic and antipyretic 2
• Paracetamol (Acetaminophen): 10-15 mg/kg every 4-6 hours for children; adult dose 500-1000 mg every 4-6 hours 2

Supportive Measures

• Warm salt water gargles
• Throat lozenges containing local anesthetics (lidocaine, benzocaine, or ambroxol) 3
• Adequate hydration
• Rest

Antibiotic Treatment Decision Algorithm

Step 1: Assess Using Centor Criteria

• Tonsillar exudates
• Tender anterior cervical lymph nodes
• Lack of cough
• Fever

Step 2: Determine Treatment Based on Score

• 0-2 Criteria: Antibiotics NOT recommended 1, 2

  • Provide symptomatic treatment only

• 3-4 Criteria: Consider antibiotics 1, 2

  • Perform rapid antigen detection test (RADT) if available
  • If RADT positive or unavailable but high clinical suspicion, proceed with antibiotics

Step 3: Antibiotic Selection (if indicated)

1. First choice: Penicillin V

   • Children: 250 mg 2-3 times daily for 10 days
   • Adults: 500 mg 2-3 times daily for 10 days 1, 2

2. Alternative (especially for children): Amoxicillin

   • 50 mg/kg once daily (maximum 1000 mg) OR
   • 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 2

3. For penicillin allergy:

   • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 2, 4
   • Erythromycin: for immediate-type hypersensitivity to penicillin
   • Cephalexin: for non-immediate reactions (if no anaphylaxis history) 2

Evidence Quality and Clinical Considerations

The recommendation for symptomatic treatment with ibuprofen or paracetamol has strong evidence (A-1 level) 1. Research suggests NSAIDs may provide better pain relief than acetaminophen for pharyngitis 5.

The evidence for antibiotic use is more nuanced:

• Antibiotics provide only modest benefits for symptom reduction 6
• They do reduce complications like acute otitis media and peritonsillar abscess (quinsy) 6
• The risk of serious complications like acute rheumatic fever is very low in most developed countries 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Most sore throats (>80%) are viral in origin 7. Unnecessary antibiotic use contributes to antimicrobial resistance.

2. Using broad-spectrum antibiotics as first-line: Despite the trend toward using newer, broader-spectrum antibiotics, penicillin remains the recommended first-line treatment for streptococcal pharyngitis due to:

   • No resistance development to penicillin
   • Narrow antimicrobial spectrum
   • Lower cost 2, 7

3. Incomplete antibiotic courses: Emphasize the importance of completing the full 10-day course of antibiotics (except for azithromycin, which is 5 days) to prevent complications and ensure complete eradication of Group A Streptococcus 2

4. Ignoring symptom timeline: Patients with Group A streptococcal pharyngitis should show improvement within 3-4 days of starting antibiotics. If not, they should be reassessed for diagnostic reconsideration or development of complications 5

5. Using local antibiotics or antiseptics: These are not recommended due to lack of efficacy data and the primarily viral origin of most sore throats 3