What is the recommended antibiotic treatment for a sore throat of bacterial origin?

Recommended Antibiotic Treatment for Bacterial Sore Throat

If antibiotics are indicated for bacterial sore throat, penicillin V taken twice or three times daily for 10 days is the recommended first-line treatment. 1

Diagnosis Before Treatment

• Use the Centor clinical scoring system to identify patients with higher likelihood of streptococcal infections 1
• For patients with high Centor scores (3-4 criteria), consider using rapid antigen testing (RAT) to confirm group A streptococcal infection 1
• If RAT is performed and negative, throat culture is not necessary for diagnosis 1
• Antibiotics should only be prescribed for patients with confirmed streptococcal pharyngitis 1

Antibiotic Treatment Recommendations

• First-line treatment: Penicillin V, twice or three times daily for 10 days 1
• Alternative for children: Amoxicillin can be used in younger children due to taste considerations and availability as syrup or suspension 1, 2
• Avoid once-daily dosing of penicillin, as it results in higher rates of persistent positive cultures and recurrences 3
• The full 10-day course is important - shorter treatment lengths (3-5 days) show inferior bacterial eradication rates and higher recurrence rates 4

When to Use Antibiotics

• Antibiotics should not be used in patients with less severe presentations (0-2 Centor criteria) 1
• Only consider antibiotics for patients with more severe presentations (3-4 Centor criteria) or positive streptococcal testing 1
• The benefit of antibiotics is modest - they shorten symptom duration by only 1-2 days 1, 5
• The number needed to treat to prevent one sore throat at day three is less than six; at week one it is 18 5

Benefits and Risks of Antibiotic Treatment

• Benefits of antibiotics must be weighed against potential side effects, impact on microbiota, increased antibiotic resistance, medicalization, and costs 1
• Antibiotics reduce the risk of suppurative complications like peritonsillar abscess (quinsy) and acute otitis media 5
• Prevention of non-suppurative complications (rheumatic fever, glomerulonephritis) is not a specific indication for antibiotic therapy in low-risk patients 1

Symptomatic Treatment

• Either ibuprofen or paracetamol (acetaminophen) are recommended for relief of acute sore throat symptoms 1
• Corticosteroids are not routinely recommended but can be considered in adult patients with severe presentations 1
• Zinc gluconate is not recommended for sore throat treatment 1

Common Pitfalls to Avoid

• Prescribing antibiotics without confirming streptococcal infection - overuse of antibiotics occurs in more than 60% of adults with sore throat 1, 6
• Using antibiotics for less severe presentations (0-2 Centor criteria) where benefits are minimal 1
• Prescribing shorter courses of antibiotics (less than 10 days), which leads to higher recurrence rates 4
• Using broad-spectrum antibiotics when narrow-spectrum options like penicillin V are effective 1, 2
• Failing to consider symptomatic treatment with analgesics, which should be offered to all patients 1