What is the treatment for a sore throat of 2 days duration?

Treatment of Sore Throat (2 Days Duration)

For a sore throat of 2 days duration, symptomatic treatment with ibuprofen or acetaminophen is the primary recommendation, and antibiotics should NOT be prescribed unless the patient has 3-4 Centor criteria or confirmed Group A streptococcal infection. 1

Initial Assessment Using Centor Criteria

Evaluate the patient using the Centor scoring system to assess likelihood of bacterial pharyngitis 1:

• Fever (temperature > 38°C): 1 point
• Absence of cough: 1 point
• Tonsillar exudates: 1 point
• Tender anterior cervical lymphadenopathy: 1 point

Risk stratification based on score 1:

• 0-2 points (Low risk): Antibiotics are NOT indicated - proceed directly to symptomatic treatment 1
• 3-4 points (Higher risk): Consider testing for Group A Streptococcus with rapid antigen detection test (RADT) before prescribing antibiotics 1

Symptomatic Treatment (First-Line for All Patients)

Analgesics for pain and fever relief 1, 2, 3:

• Ibuprofen or acetaminophen (paracetamol) are strongly recommended 1, 2, 3
• Aspirin is acceptable in adults but should be avoided in children due to Reye syndrome risk 3
• Throat lozenges may provide additional symptomatic relief 1, 2

Supportive measures 2, 3:

• Salt water gargles 1
• Adequate hydration with cool liquids 3
• Viscous lidocaine for topical pain relief (though limited evidence) 1

When to Consider Antibiotics

Antibiotics should ONLY be prescribed if 1:

• Patient has 3-4 Centor criteria AND positive RADT for Group A Streptococcus 1
• Patient has history of rheumatic fever (high-risk patient) 1

Important context on antibiotic benefits 1, 2:

• Antibiotics reduce symptoms by only 1-2 days in confirmed streptococcal pharyngitis 1, 2
• The number needed to treat is 6 to prevent one sore throat at day 3, and 21 at one week 1, 2
• 82% of patients are symptom-free by one week regardless of antibiotic use 4
• Most sore throats resolve in less than 7 days without antibiotics 2

Antibiotic Selection (If Indicated)

First-line antibiotic choice 1, 5:

• Penicillin V: 500 mg twice or three times daily for 10 days 1
• Amoxicillin: Alternative option, particularly in younger children due to better taste and syrup formulation 1, 6, 5
  • Adults: 500 mg every 12 hours or 250 mg every 8 hours for 10 days 5
  • Children ≥3 months and <40 kg: 25 mg/kg/day divided every 12 hours or 20 mg/kg/day divided every 8 hours 5

Alternative antibiotics for penicillin allergy 3:

• First-generation cephalosporins 3
• Clindamycin 3
• Macrolides (clarithromycin) 3

Duration of treatment 1, 5:

• Minimum 10 days for any infection caused by Streptococcus pyogenes to prevent acute rheumatic fever 1, 5
• Shorter courses (5-7 days) show small clinical differences favoring 10-day treatment 1

Delayed Prescribing Strategy

Valid option for moderate-risk patients (3 Centor criteria) 1:

• Provide prescription but advise patient to wait 48 hours before filling it 1
• No significant differences in complication rates between delayed antibiotics, immediate antibiotics, or no antibiotics 1
• This approach reduces antibiotic use while maintaining safety 1

Common Pitfalls to Avoid

Do NOT prescribe antibiotics to prevent complications in low-risk patients 1:

• The absolute risk of rheumatic fever and acute glomerulonephritis is extremely small in modern Western settings 1
• Number needed to treat to prevent one case of quinsy is 27 or higher, and 50-200 in modern primary care 1

Do NOT use antibiotics for viral pharyngitis 1, 2, 3:

• Over 60% of adults with sore throat receive antibiotics despite most cases being viral 1
• Antibiotics provide no benefit for viral infections and increase risk of side effects and antimicrobial resistance 1, 2

Do NOT use broad-spectrum antibiotics as first-line 6:

• Amoxicillin-clavulanate should be reserved for retreatment of multiple repeated culture-positive episodes, not initial treatment 6
• Broad-spectrum antibiotics increase resistance and side effects without additional clinical benefit 6

Avoid amoxicillin in older children/adolescents with suspected mononucleosis 1:

• Risk of severe rash if Epstein-Barr virus infection is present 1

Red Flags Requiring Urgent Evaluation

Immediately evaluate for serious complications if patient has 1:

• Difficulty swallowing or drooling 1
• Neck tenderness or swelling 1
• Severe unilateral throat pain (peritonsillar abscess) 1
• Respiratory distress 3
• Inability to maintain oral hydration 3

Patient Education

Counsel patients that 1, 2:

• Typical sore throat lasts less than 1 week 1, 2
• Antibiotics are usually not needed and do little to alleviate symptoms 1, 2
• Symptomatic treatment with analgesics is effective for pain relief 1, 2
• Most cases resolve without complications 2