What are the management options for a sore throat?

Sore Throat Management

For sore throat management, antibiotics should only be prescribed when a patient has 3-4 Centor criteria suggesting a high likelihood of streptococcal infection, with penicillin V as the first-line treatment for confirmed Group A Streptococcal pharyngitis. 1

Diagnostic Approach

Clinical Assessment

• Use Centor criteria to assess likelihood of streptococcal infection:
  • Fever
  • Absence of cough
  • Tonsillar exudate
  • Swollen tender anterior cervical lymph nodes

Testing Recommendations

• For patients with 0-2 Centor criteria: No antibiotics or testing needed
• For patients with 3-4 Centor criteria: Perform Rapid Antigen Detection Test (RADT)
  • For children: Use RADT with throat culture backup for negative results
  • For adults: Negative RADTs do not routinely require backup cultures 1

Treatment Algorithm

1. Symptomatic Treatment (First-Line)

• NSAIDs are recommended as first-line treatment:
  • Ibuprofen shows the best benefit-risk profile 2
  • Naproxen is also effective 3
  • Acetaminophen/paracetamol is an alternative option 1
  • Flurbiprofen has shown efficacy but lacks head-to-head comparison data 2

2. Local Treatments

• Local anesthetics with confirmed efficacy:
  • Lidocaine (8mg)
  • Benzocaine (8mg)
  • Ambroxol (20mg) - best documented benefit-risk profile 2
• Note: Local antibiotics or antiseptics are not recommended due to mainly viral origin and lack of efficacy data 2

3. Antibiotic Treatment

• Only when indicated (3-4 Centor criteria and positive RADT):
  • First-line: Penicillin V (250mg three times daily or 500mg twice daily for 10 days in adults) 1
  • Alternative: Amoxicillin (50mg/kg once daily or 25mg/kg twice daily for 10 days) 1, 4
  • For penicillin allergy: Cephalexin or macrolides (e.g., azithromycin 12mg/kg once daily for 5 days) 1, 5

Benefits and Risks of Antibiotic Treatment

Benefits

• Modest symptom reduction (1-2 days) 1, 6
• Reduction in complications:
  • Acute otitis media (high-certainty evidence) 6
  • Quinsy/peritonsillar abscess (high-certainty evidence) 6
  • Acute rheumatic fever (moderate-certainty evidence, though rare in modern settings) 6

Risks

• Side effects (primarily gastrointestinal):
  • With azithromycin: 4-16.8% (vs. 20-31% with comparators) 5
  • Development of antimicrobial resistance 1
  • Impact on microbiota 1

Special Considerations

Treatment Duration

• Minimum of 10 days for GAS pharyngitis to prevent acute rheumatic fever 1, 4
• Seven-day penicillin treatment has shown superior efficacy compared to three-day treatment 7

Prevention and Control

• Hand hygiene
• Avoid close contact with infected individuals
• Don't share utensils or drinks
• Healthcare workers with GAS infection should be excluded from work until 24 hours of appropriate treatment and symptom resolution 1

When to Consider Specialist Referral

• Recurrent throat infections meeting specific frequency criteria (≥7 episodes in past year, ≥5 episodes per year in past 2 years, or ≥3 episodes per year in past 3 years) may warrant consideration for tonsillectomy 1
• Development of complications like peritonsillar abscess 7

Key Pitfalls to Avoid

1. Prescribing antibiotics for likely viral sore throats (0-2 Centor criteria)
2. Using antibiotics for less than the recommended duration (10 days for GAS)
3. Failing to use clinical scoring systems to guide antibiotic decisions
4. Recommending local antibiotics or antiseptics without evidence of efficacy
5. Not considering delayed antibiotic prescriptions for patients with moderate risk (3 Centor criteria)

Remember that most sore throats are self-limiting with a mean duration of 7 days, and 82% of patients are symptom-free by one week even without antibiotics 3, 6.