What is the treatment for a sore throat?

Treatment of Sore Throat

For acute sore throat, start with ibuprofen or paracetamol for symptom relief, and reserve antibiotics only for patients with 3-4 Centor criteria after discussing the modest benefits against significant risks. 1

First-Line Symptomatic Treatment

Either ibuprofen or paracetamol are strongly recommended as first-line analgesics for acute sore throat pain. 2, 1

• Ibuprofen shows slightly better efficacy than paracetamol for pain relief, particularly after 2 hours of administration 1
• Both medications are safe when used according to directions for short-term treatment, with low risk of adverse effects 1
• Treatment should focus on symptom relief since most sore throats are viral and self-limiting 2

Clinical Assessment Using Centor Criteria

Before considering antibiotics, assess the patient using the Centor scoring system (0-4 points): 2, 1, 3

• Fever (1 point)
• Absence of cough (1 point)
• Tonsillar exudates (1 point)
• Tender anterior cervical lymphadenopathy (1 point)

Antibiotic Decision Algorithm

Patients with 0-2 Centor Criteria:

Do NOT prescribe antibiotics. 2, 1, 4

• Antibiotics provide no meaningful benefit for symptom relief in this group 2
• The presentation is too mild to warrant antibiotic therapy 4
• Rapid antigen testing is not routinely needed 2

Patients with 3-4 Centor Criteria:

Consider antibiotics only after discussing modest benefits versus risks with the patient. 2, 1, 4

• Physicians can consider using rapid antigen tests (RAT) in this group 2
• If RAT is performed, throat culture is not necessary after a negative RAT 2
• Antibiotics reduce symptoms on day 3 (relative risk 0.72), but benefits must be weighed against side effects, antimicrobial resistance, medicalization, and costs 2
• At 1 week, only group A β-hemolytic streptococcus-positive patients show continued benefit 2

Antibiotic Therapy (When Indicated)

If antibiotics are indicated, penicillin V twice or three times daily for 10 days is the recommended first-line agent. 2, 1, 4

• There is insufficient evidence to support shorter treatment duration 2
• Treatment should continue for at least 10 days for any infection caused by Streptococcus pyogenes to prevent acute rheumatic fever 5

What NOT to Use

Avoid these interventions as they lack evidence or are not indicated:

• Zinc gluconate is not recommended for sore throat treatment 2, 1, 4
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended 2, 1, 4
• Corticosteroids are not routinely recommended, though can be considered in adult patients with severe presentations (3-4 Centor criteria) in conjunction with antibiotics 2, 1, 4

Critical Pitfalls to Avoid

Antibiotics should NOT be used to prevent complications in low-risk patients: 2, 4

• Rheumatic fever and acute glomerulonephritis prevention is not justified in low-risk patients (those without previous rheumatic fever) 2
• The absolute risk of these complications is extremely small in the Western world 2
• The number needed to treat to prevent one case of quinsy (peritonsillar abscess) is 27 or higher, and between 50-200 in modern primary care settings 2
• Antibiotics do not reduce the incidence of acute sinusitis 2

Recognize that most sore throats are viral: 3, 6

• Respiratory viruses account for the majority of cases, including rhinovirus, coronavirus, adenovirus, influenza, and respiratory syncytial virus 3
• Group A β-hemolytic streptococcus accounts for only 15-30% of pharyngitis in children and 5-15% in adults 3
• Viral pharyngitis is suggested by conjunctivitis, cough, hoarseness, coryza, diarrhea, or viral exanthem 3

Be aware of chronic carriers: 3

• Chronic group A streptococcal carriers (10.9% in children ≤14 years, 2.3% in adults 15-44 years) with intercurrent viral infections are difficult to differentiate from acute infection 3
• Carriers show extremely low risk of post-streptococcal complications and low likelihood of transmission 3
• Antimicrobial therapy is NOT indicated for the majority of chronic carriers 3