What is the recommended management for a sore throat?

Management of Acute Sore Throat

For most cases of sore throat, symptomatic treatment with ibuprofen or paracetamol is recommended as first-line therapy, with antibiotics reserved only for patients with high likelihood of streptococcal infection (3-4 Centor criteria). 1, 2

Diagnosis and Assessment

Clinical Evaluation

• Use Centor criteria to assess likelihood of Group A Streptococcal (GAS) pharyngitis:

  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough
  • History of fever

• Scoring:

  • 0-2 criteria: Low risk of GAS (antibiotics not indicated)
  • 3 criteria: Moderate risk (consider testing or delayed antibiotics)
  • 4 criteria: High risk (consider immediate antibiotics or testing) 2

Diagnostic Testing

• Rapid Antigen Detection Tests (RADTs) should be considered only in patients with high likelihood of streptococcal infections (3-4 Centor criteria) 1
• If RAT is performed, throat culture is not necessary after a negative RAT for diagnosis of GAS in both children and adults 1
• Routine biomarker testing (CRP, procalcitonin) is not necessary in the assessment of acute sore throat 1

Treatment Algorithm

1. Symptomatic Treatment (First-Line for Most Cases)

• Analgesics/Antipyretics:

  • Ibuprofen or paracetamol are recommended for relief of acute sore throat symptoms (Grade A-1 evidence) 1
  • Ibuprofen may have the best benefit-risk profile based on clinical trials 3

• Supportive Measures:

  • Maintain adequate hydration
  • Warm salt water gargles
  • Cold liquids or ice chips 2

2. Antibiotic Therapy (Only for Selected Cases)

• Indications:

  • Patients with 3-4 Centor criteria may benefit from antibiotics 1, 2
  • Benefits must be weighed against side effects, impact on microbiota, antibiotic resistance, and costs 1

• First-line antibiotic:

  • Penicillin V, twice or three times daily for 10 days (Grade A-1 evidence) 1
  • For penicillin-allergic patients: first-generation cephalosporins (if not anaphylactically sensitive) or clindamycin 2

• Alternative regimens:

  • Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days (for penicillin-allergic patients) 2, 4

3. Adjunctive Therapy

• Corticosteroids are not routinely recommended but can be considered in adult patients with severe presentations (3-4 Centor criteria) 1, 2
• Zinc gluconate is not recommended for use in sore throat (Grade B-2 evidence) 1
• There is inconsistent evidence for herbal treatments and acupuncture (Grade C-1 to C-3) 1

Important Considerations

When to Avoid Antibiotics

• Antibiotics should not be used in patients with less severe presentation (0-2 Centor criteria) 1
• Sore throat should not be treated with antibiotics to prevent rheumatic fever and acute glomerulonephritis in low-risk patients 1
• Prevention of suppurative complications is not a specific indication for antibiotic therapy 1

Benefits of Antibiotics When Indicated

• Modest reduction in symptom duration (approximately 16 hours) 5
• Reduced incidence of complications such as acute otitis media and quinsy 5
• Patients are considered non-contagious after 24 hours of effective antibiotic therapy 2

Pitfalls to Avoid

• Overuse of antibiotics for predominantly viral infections
• Using antibiotics for symptom relief in mild cases
• Failure to use clinical scoring systems to guide antibiotic use
• Prescribing antibiotics for prevention of complications in low-risk patients
• Using local antibiotics or antiseptics which lack efficiency data 3

Special Populations

• Children under 3 years: testing for GAS pharyngitis usually not indicated 2
• Recurrent episodes should be evaluated to determine if the patient is experiencing true GAS infections or is a chronic carrier with viral infections 2
• Follow-up throat cultures are not routinely indicated for asymptomatic patients who have completed appropriate therapy 2

By following this evidence-based approach, clinicians can effectively manage sore throat while minimizing unnecessary antibiotic use and its associated consequences.