What are the guidelines for managing a sore throat?

Guidelines for Managing Acute Sore Throat

Most cases of acute sore throat are viral in origin and should be managed with symptomatic treatment, with antibiotics reserved only for cases with high likelihood of streptococcal infection based on clinical scoring and confirmatory testing. 1

Diagnostic Approach

• Use the Centor clinical scoring system to identify patients with higher likelihood of group A streptococcal infection, which includes: fever by history, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough 2, 3
• Patients with fewer than 3 Centor criteria do not need testing for group A streptococcus as they have a low probability of streptococcal pharyngitis 2, 3
• For patients with 3-4 Centor criteria, consider using rapid antigen tests (RATs) to confirm streptococcal infection 2, 3
• If RAT is performed and negative, throat culture is not necessary in adults but is recommended in children and adolescents 2, 4

Treatment Recommendations

Symptomatic Treatment (First-Line for Most Cases)

• Offer analgesic therapy to all patients with sore throat for pain relief 3
• Either ibuprofen or paracetamol (acetaminophen) is recommended as first-line treatment for symptom relief 5, 3
• Symptomatic treatments can be administered at the start of a meal to minimize gastrointestinal intolerance 6
• There is inconsistent evidence supporting herbal treatments or other complementary therapies for sore throat 5, 3

Antibiotic Treatment (Only When Indicated)

• Antibiotics should NOT be used in patients with less severe presentation (0-2 Centor criteria) 1, 2
• For patients with 3-4 Centor criteria and positive testing, consider antibiotics after discussing that benefits are modest (shortening symptoms by only 1-2 days) 1, 3
• If antibiotics are indicated:
  • Penicillin V, twice or three times daily for 10 days, is the recommended first-line treatment 1, 5
  • Amoxicillin is an acceptable alternative to penicillin V, particularly in younger children due to better taste and availability as syrup 5, 4
  • For streptococcal infections, treatment should continue for at least 10 days to prevent acute rheumatic fever 6
  • Amoxicillin-clavulanate should only be considered for retreatment of patients with multiple repeated culture-positive episodes of pharyngitis 5

Special Considerations

• The typical course of sore throat is less than one week; reassure patients about this expected timeline 3, 7
• Most cases (>65%) of sore throat are viral in origin and self-limiting 3, 8
• Watch for red flags that may indicate complications requiring more aggressive intervention:
  • Peritonsillar abscess (quinsy) 3
  • Lemierre syndrome in adolescents and young adults with severe pharyngitis 3
  • Severe systemic infections or immunosuppression 7
• Tonsillectomy should only be considered for very frequent, documented recurrent infections (commonly defined as seven episodes in 1 year, five episodes in each of the past 2 years, or three episodes in each of the past 3 years) 9, 4

Common Pitfalls to Avoid

• Using antibiotics to prevent complications like rheumatic fever in low-risk patients is not recommended 5
• Using broad-spectrum antibiotics like amoxicillin-clavulanate as first-line therapy increases antibiotic resistance and side effects without providing additional clinical benefit 5
• Treating viral sore throats (most cases with 0-2 Centor criteria) with antibiotics contributes to antimicrobial resistance 5, 8
• Failing to consider patient expectations and concerns about their condition, which can drive unnecessary antibiotic use 8

By following these evidence-based guidelines, clinicians can provide appropriate care for patients with sore throat while promoting antibiotic stewardship and reducing unnecessary treatments.