What are the management options for a sore throat?

Management Options for Sore Throat

The primary management options for sore throat include symptomatic treatment with ibuprofen or paracetamol, with antibiotics reserved only for cases with high likelihood of streptococcal infection (3-4 Centor criteria). 1, 2

Assessment and Diagnosis

Before determining treatment, assess the severity using clinical scoring systems:

Centor Criteria:

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

Management Algorithm Based on Centor Score:

1. Low risk (0-2 Centor criteria):

   • No antibiotics needed
   • No rapid antigen testing needed
   • Focus on symptomatic treatment only 1, 2

2. Moderate risk (3 Centor criteria):

   • Consider rapid antigen detection test (RADT)
   • Consider delayed antibiotic prescription
   • Symptomatic treatment 1, 2, 3

3. High risk (4 Centor criteria):

   • Consider RADT
   • Immediate antibiotics may be justified
   • Symptomatic treatment 1, 2

First-Line Treatment Options

Symptomatic Treatment (For All Patients)

• NSAIDs: Ibuprofen is recommended as first-line for relief of acute sore throat symptoms 1, 4

  • Provides effective relief for pain, difficulty swallowing, and throat swelling
  • Slightly better efficacy as both analgesic and antipyretic compared to paracetamol 2

• Paracetamol (Acetaminophen): Alternative first-line option 1

  • Particularly useful when NSAIDs are contraindicated

• Additional symptomatic measures:

  • Warm salt water gargles
  • Throat lozenges (flurbiprofen 8.75 mg lozenges have shown effectiveness) 4
  • Adequate hydration
  • Rest 2, 5

Antibiotic Treatment (Only for Selected Cases)

• When to consider antibiotics:

  • Patients with 3-4 Centor criteria
  • Group A β-hemolytic streptococcus (GABHS) positive patients
  • Patients at high risk of complications 1, 2

• First-line antibiotic:

  • Penicillin V for 10 days (250-500 mg 2-3 times daily) 1, 2

• For penicillin-allergic patients:

  • Clarithromycin or erythromycin for immediate-type hypersensitivity
  • First-generation cephalosporins for non-immediate reactions 2

• Alternative option:

  • Azithromycin (12 mg/kg once daily, max 500 mg) for 5 days 2, 6
  • Amoxicillin (50 mg/kg once daily or 25 mg/kg twice daily) for 10 days 2, 7

Important Considerations

• Duration of symptoms: Most sore throats are self-limiting with a mean duration of 7 days 3, 5

• Antibiotic benefits are modest: Even in GABHS-positive patients, antibiotics only modestly reduce symptom duration 1, 8

• Complete the full antibiotic course: If prescribed, complete the full 10-day course (except for azithromycin which is 5 days) to prevent complications like acute rheumatic fever 2, 7

• Corticosteroids: Not routinely recommended but may be considered in adults with severe presentations (3-4 Centor criteria) 1

• Not recommended:

  • Zinc gluconate 1
  • Local antibiotics or antiseptics 9
  • Routine biomarker testing (CRP, procalcitonin) 1

Cautions and Red Flags

• Watch for red flags requiring urgent attention:

  • Immunosuppression
  • Severe systemic infections
  • Difficulty breathing or swallowing
  • Significant voice changes
  • Inability to handle secretions 3

• Antibiotic stewardship: Overuse of antibiotics contributes to antimicrobial resistance. Most sore throats (>65%) are viral in origin and do not require antibiotics 3, 5

• Patient education: Explain the self-limiting nature of most sore throats and that antibiotics provide only modest benefit even in bacterial cases 5, 8