What are the treatment options for a sore throat?

Treatment of Sore Throat

For acute sore throat, start with systemic analgesics—specifically ibuprofen as first-line (if no contraindications) or paracetamol as an alternative—and reserve antibiotics only for patients with high probability of Group A Streptococcal infection based on clinical scoring. 1, 2

Symptomatic Treatment (First-Line for All Patients)

Systemic analgesics are the cornerstone of sore throat management, as most cases are viral and self-limiting with a mean duration of 7 days. 3

• Ibuprofen is the preferred first-line systemic analgesic, showing slightly better efficacy than paracetamol for pain relief, particularly after 2 hours of administration. 1, 2
• Paracetamol is an effective alternative when ibuprofen is contraindicated, with both medications considered safe for short-term use according to directions. 1, 2
• Both medications have strong evidence supporting their use and low risk of adverse effects. 1, 2

Topical Adjunctive Options

• Local anesthetic sprays or lozenges can be considered as adjunctive therapy for additional symptom relief. 1
• Lidocaine (8mg), benzocaine (8mg), and ambroxol (20mg) have confirmed efficiency in clinical trials, with ambroxol having the best documented benefit-risk profile. 4
• Flurbiprofen 8.75 mg spray provides rapid relief (within 5 minutes) and long-lasting symptom reduction for up to 6 hours. 5

What NOT to Use

• Do not recommend local antibiotics or antiseptics due to the mainly viral origin of sore throats and lack of efficacy data. 1, 4
• Zinc gluconate is not recommended due to conflicting efficacy results and increased adverse effects. 1
• Herbal remedies and alternative treatments lack reliable efficacy data and should not be recommended. 1, 2

Antibiotic Decision-Making Algorithm

Antibiotics should only be considered after risk stratification using clinical scoring systems. 3, 6

Step 1: Exclude Red Flags

• Evaluate for severe systemic infection, immunosuppression, difficulty swallowing, drooling, neck tenderness/swelling, or signs of peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome. 7, 3

Step 2: Apply Clinical Scoring (Centor, McIsaac, or FeverPAIN)

• Low risk (< 3 points): No antibiotics indicated 3
• Moderate risk (3 points): Consider delayed prescription 3
• High risk (> 3 points): Antibiotics can be taken immediately 3

Step 3: Consider Testing

• Rapid antigen detection testing and/or throat culture for Group A Streptococcus should be performed when the result will influence therapeutic decision-making. 7, 6
• Testing is most useful in patients with clinical signs suggestive of bacterial pharyngitis (sudden onset, fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough). 7

Antibiotic Selection When Indicated

When antibiotics are warranted, penicillin remains first-line therapy. 7, 3

First-Line Antibiotic

• Penicillin V for 10 days is the recommended first-line treatment for confirmed Group A Streptococcal tonsillitis. 7
• Amoxicillin is an acceptable alternative for upper respiratory tract infections due to susceptible Streptococcus species. 8

Penicillin-Allergic Patients

• Non-anaphylactic allergy: First-generation cephalosporins 7
• Anaphylactic allergy: Clindamycin, azithromycin, or clarithromycin 7, 3

Treatment Failures

• Amoxicillin-clavulanate, clindamycin, or second/third-generation cephalosporins 7

Duration

• Antibiotics should be taken for 5-7 days minimum, with at least 10 days for Streptococcus pyogenes to prevent acute rheumatic fever. 7, 8, 3
• Short courses are less effective for Group A Streptococcus eradication and should be avoided. 7

Critical Pitfalls to Avoid

• Do not initiate antibiotics without confirming Group A Streptococcus infection through clinical scoring and/or testing, as this leads to unnecessary antibiotic use. 7
• Do not use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed Group A Streptococcus. 7
• Do not routinely use corticosteroids in self-care settings; they may only be considered in conjunction with antibiotics for severe presentations under medical supervision. 1, 2
• Do not perform follow-up throat cultures for asymptomatic patients who have completed appropriate antibiotic therapy. 7
• Even when antibiotics are indicated, recognize that they only modestly shorten symptom duration (at best). 3, 6

Special Considerations

• Pediatric patients: Both ibuprofen and paracetamol are effective with no significant difference in analgesic efficacy or safety. 1, 2
• Recurrent tonsillitis: Tonsillectomy can be considered for recurrent, documented episodes meeting Paradise criteria. 7