Management of Sore Throat Due to Upper Respiratory Infection
For most adults with sore throat from URI, offer ibuprofen or paracetamol (acetaminophen) for symptomatic relief and avoid antibiotics unless group A streptococcal pharyngitis is confirmed by testing. 1, 2
Symptomatic Treatment (First-Line for All Patients)
Analgesics are the cornerstone of management for URI-related sore throat, as most cases are viral and self-limiting within 7 days. 1, 3
- Ibuprofen is slightly more effective than paracetamol for pain relief, particularly after 2 hours of administration 1, 2
- Both medications are equally safe when used short-term according to usual contraindications 1
- Aspirin is also effective and reduces throat soreness, headache, and muscle aches to about half within 3.5 days 4, 5
- Throat lozenges can provide additional topical relief 1
- Do NOT use zinc gluconate (not recommended due to conflicting efficacy and increased adverse effects) 6, 2
- Avoid local antibiotics or antiseptics (lack efficacy data and most sore throats are viral) 2
When to Consider Bacterial Testing
Use clinical scoring systems to identify patients who need testing for group A Streptococcus (GAS). 1, 3
Apply the Centor criteria (or McIsaac/FeverPAIN scores):
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough
- Fever (>38°C)
Risk-Stratified Approach:
- 0-2 criteria (low risk): Do NOT test or treat with antibiotics 1, 6, 3
- 3 criteria (moderate risk): Consider rapid antigen detection test (RADT); if positive, treat; if negative, no throat culture needed 6, 3
- 4 criteria (high risk): Perform RADT and/or culture; treat if positive 1, 6
Clinical scoring combined with rapid tests is more effective than clinical scoring alone for reducing unnecessary antibiotic use. 1
Antibiotic Treatment (Only for Confirmed GAS)
If GAS is confirmed by testing, prescribe penicillin V for 10 days (first-line choice due to proven efficacy, narrow spectrum, safety, and low cost). 1, 6, 2
Alternative regimens:
- Amoxicillin (acceptable alternative, especially in children due to better taste and syrup formulation) 1, 6
- Clarithromycin (for penicillin-allergic patients) 3
- Treatment duration: 5-10 days (most guidelines recommend 10 days) 1, 6, 3
Important Caveats About Antibiotic Benefits:
- Antibiotics shorten symptom duration by only 1-2 days (number needed to treat = 6 at day 3, and 21 at week 1) 1, 7
- About 90% of patients are symptom-free by one week regardless of antibiotic use 7
- Benefits include prevention of acute rheumatic fever (reduces risk to less than one-third), peritonsillar abscess, and acute otitis media 1, 7
- Little evidence supports prevention of acute glomerulonephritis 1
What NOT to Do
- Do NOT prescribe amoxicillin-clavulanate as first-line therapy (broad-spectrum increases resistance and side effects without additional benefit; reserve for retreatment of multiple culture-positive recurrent episodes) 6
- Do NOT treat chronic GAS carriers (unlikely to spread infection and at little risk for complications) 1
- Do NOT use antibiotics for viral sore throat (>60% of adults receive unnecessary prescriptions despite viral etiology in most cases) 1, 8
- Avoid herbal remedies and acupuncture (inconsistent evidence supporting efficacy) 1, 2
Patient Counseling
Educate patients that:
- Typical sore throat duration is less than 1 week 1
- Most cases are viral and self-limiting 8, 3
- Antibiotics provide modest benefit (shortening symptoms by about 16 hours overall) and carry risks of side effects, microbiota disruption, and resistance 1, 7
- Effective self-management with analgesics is appropriate for most cases 8, 3