What is the recommended treatment for a sore throat?

Sore Throat Treatment

The recommended first-line treatment for sore throat is symptomatic management with NSAIDs (particularly ibuprofen) or acetaminophen for pain relief, along with appropriate antibiotic therapy only when Group A Streptococcal (GAS) infection is confirmed or highly suspected based on clinical criteria. 1, 2, 3

Diagnosis and Assessment

Before initiating treatment, determine the likelihood of bacterial versus viral etiology:

• Use clinical scoring systems:

  • Centor Criteria: Tonsillar exudates, tender anterior cervical lymph nodes, lack of cough, and fever 1
  • FeverPAIN Score: Similar clinical criteria to assess bacterial likelihood 4

• Testing recommendations:

  • Patients with 0-2 Centor criteria: No testing needed (likely viral)
  • Patients with 3-4 Centor criteria: Perform Rapid Antigen Detection Test (RADT) and/or throat culture 1
  • Clinical features suggesting viral etiology (cough, rhinorrhea, hoarseness, oral ulcers): Testing not required 1

Treatment Algorithm

1. Symptomatic Management (All Patients)

• First-line pain relief:

  • Ibuprofen (shows best benefit-risk profile) 3
  • Acetaminophen as an alternative 1, 3
  • NSAIDs are more effective than acetaminophen for fever and pain 4

• Supportive measures:

  • Throat lozenges with local anesthetics (lidocaine, benzocaine, or ambroxol) every 2 hours 3, 4
  • Warm salt water gargles 1
  • Cold liquids or ice chips for hydration 1
  • Avoid hot liquids, spicy foods, and hard foods that may irritate the throat 1

2. Antibiotic Therapy (Only for Confirmed/Highly Suspected Bacterial Infection)

• Indications for antibiotics:

  • Confirmed GAS by testing
  • High clinical suspicion (Centor score >3) 1, 2

• First-line antibiotic regimen:

  • Amoxicillin: 50 mg/kg/day divided into two doses (maximum 1000 mg per dose) for 10 days 1, 5
  • Penicillin V: 500 mg 2-3 times daily for 10 days 1

• For penicillin-allergic patients:

  • Non-anaphylactic allergy: First-generation cephalosporins for 10 days
  • Anaphylactic allergy: Clindamycin (300-450 mg three times daily for 10 days), clarithromycin, or azithromycin 1

Important Considerations

• Duration of therapy: A full 10-day course of antibiotics is mandatory for confirmed streptococcal pharyngitis to prevent acute rheumatic fever 1, 5

• Treatment effectiveness: Antibiotics reduce symptoms of sore throat at day three (RR 0.70) and at one week (RR 0.50) compared to placebo, with NNTB of less than 6 and 18 respectively 6

• Complication prevention: Antibiotics reduce the incidence of acute otitis media, quinsy (peritonsillar abscess), and acute rheumatic fever 6

• Return to school/work: Patients should complete at least 24 hours of antibiotics before returning to school or work to reduce transmission risk 1

• Treatment failure: If symptoms persist after 48-72 hours of antibiotic therapy, reevaluation is necessary 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Most sore throats (65-95%) are viral in origin and do not require antibiotics 2, 4

2. Inadequate duration of therapy: For confirmed streptococcal pharyngitis, a full 10-day course is necessary to prevent complications, particularly acute rheumatic fever 1, 5

3. Using aspirin in children: Avoid aspirin in children due to the risk of Reye syndrome 1

4. Neglecting symptomatic relief: Even when antibiotics are indicated, symptomatic management remains essential for patient comfort 1, 3

5. Using local antibiotics or antiseptics: Due to the mainly viral origin of sore throat and lack of efficacy data, local antibiotics or antiseptics should not be recommended 3