What is the appropriate treatment for a patient with a history of sore throat?

Management of Acute Sore Throat

Most patients with acute sore throat should receive symptomatic treatment with ibuprofen or paracetamol only, without antibiotics, as the majority of cases are viral and self-limiting. 1

Initial Assessment: Risk Stratification Using Clinical Scoring

• Apply the Centor criteria to assess likelihood of Group A streptococcal (GABHS) infection, which includes: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2

• Patients with 0-2 Centor criteria have low probability of GABHS and should not receive antibiotics or testing—these patients require symptomatic treatment only 1

• Patients with 3-4 Centor criteria have higher probability of GABHS and warrant consideration for rapid antigen detection testing (RAT) before any antibiotic decision 1

• The Centor system works better in adults than children, as clinical presentation differs in younger age groups 1

Diagnostic Testing Strategy

• Throat culture is not necessary for routine diagnosis of acute sore throat 1

• If RAT is performed and negative, throat culture is not necessary in either children or adults 1

• RAT should only be considered in patients with 3-4 Centor criteria—there is no role for testing in patients with 0-2 criteria 1

• Biomarkers like C-reactive protein or procalcitonin are not routinely indicated in assessment of acute sore throat 1

Symptomatic Treatment (First-Line for All Patients)

• Either ibuprofen or paracetamol are recommended for relief of acute sore throat symptoms 1, 3

• NSAIDs like ibuprofen are more effective than acetaminophen for fever and pain control 4

• For patients with renal impairment, paracetamol is the safer choice due to NSAID risks 3

• Medicated throat lozenges used every two hours can provide additional symptom relief 4

Antibiotic Decision-Making: A Restrictive Approach

Antibiotics should NOT be used in the following scenarios:

• Patients with 0-2 Centor criteria should never receive antibiotics for symptom relief 1, 3

• Prevention of suppurative complications (quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis) is not an indication for antibiotics 1, 3

• Prevention of rheumatic fever or acute glomerulonephritis in low-risk patients (no previous history of rheumatic fever) is not an indication for antibiotics 1, 3

When antibiotics may be considered (3-4 Centor criteria):

• Discuss the modest benefits with patients and weigh against side effects, impact on microbiota, antimicrobial resistance, medicalization, and costs 1, 3

• Even in GABHS-positive patients with high Centor scores, antibiotics only modestly shorten symptom duration 1, 5

• The evidence shows antibiotics reduce symptom duration by approximately 16 hours on average 5

Antibiotic Selection (When Indicated)

• Penicillin V is the first-choice antibiotic, given twice or three times daily for 10 days 1, 3, 6, 4

• For penicillin-allergic patients (non-anaphylactic): first-generation cephalosporins are appropriate 2, 6

• For penicillin-allergic patients (anaphylactic): clindamycin, azithromycin, or clarithromycin 2, 6

• Azithromycin (12 mg/kg once daily for 5 days in children) showed 95% bacteriologic eradication at Day 14 versus 73% with penicillin V, though gastrointestinal side effects were higher (18% vs 13%) 7

• Treatment duration matters: shorter courses are less effective for GABHS eradication and should be avoided 6

Corticosteroids: Limited Role

• Corticosteroids are not routinely recommended for treatment of sore throat 1

• They can be considered in adult patients with severe presentations (3-4 Centor criteria) in conjunction with antibiotics, but provide only small reductions in symptom duration 1, 4

What NOT to Use

• Zinc gluconate is not recommended for sore throat 1, 3

• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended 1, 3

Red Flags Requiring Urgent Evaluation

• Severe cases with difficulty swallowing, drooling, neck tenderness, or swelling suggest peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome 2, 6

• Immunosuppression or signs of severe systemic infection require immediate evaluation 5

• Persistent fever, neck pain, and septic emboli suggest Lemierre's syndrome (suppurative thrombophlebitis of internal jugular vein) 2

Common Clinical Pitfalls

• Avoid prescribing antibiotics based on patient pressure or expectations alone—effective communication about the viral nature and self-limiting course is essential 8, 5

• Do not perform throat cultures after negative RAT—this leads to unnecessary antibiotic use 1

• Do not use clinical appearance alone to distinguish bacterial from viral pharyngitis—microbiological confirmation is required when GABHS is suspected in high-risk patients 2

• Chronic GABHS carriers (10.9% in children ≤14 years, 2.3% in adults) with intercurrent viral infections are difficult to distinguish from acute infection but have extremely low risk of complications and do not require treatment 2

• Follow-up throat cultures are not recommended for asymptomatic patients who completed appropriate antibiotic therapy 6