Treatment of Sore Throat
For most patients with acute sore throat, start with ibuprofen or paracetamol for symptom relief and avoid antibiotics unless the patient has 3-4 Centor criteria, in which case discuss the modest benefits versus risks before prescribing penicillin V for 10 days. 1
Initial Symptomatic Management
- Either ibuprofen or paracetamol are the recommended first-line treatments for acute sore throat pain relief 1, 2
- Both agents show equivalent efficacy and safety for short-term use, though ibuprofen demonstrates superior pain relief compared to paracetamol in head-to-head trials 3
- Naproxen is also an effective option for symptomatic treatment 4
- Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg) can be recommended as first-line treatment for patients requesting topical therapy 5
Risk Stratification Using Centor Criteria
Before considering antibiotics, assess the patient using the Centor scoring system, which includes: 1, 2
- Fever (temperature >38°C)
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough
Each criterion present = 1 point (maximum 4 points) 1
Antibiotic Decision Algorithm
Centor Score 0-2 (Low Risk)
- Do NOT prescribe antibiotics 1, 2
- Antibiotics provide no meaningful benefit in this group and should not be used to relieve symptoms 1
- Continue symptomatic treatment with analgesics 1
Centor Score 3-4 (Higher Risk)
- Consider rapid antigen detection test (RADT) to confirm group A streptococcal infection 1
- If RADT is performed and negative, throat culture is NOT necessary 1
- Discuss with the patient that antibiotics provide only modest symptom relief (shortening symptoms by approximately 1 day) and must be weighed against side effects, antimicrobial resistance, medicalization, and costs 1
- Even in this higher-risk group, delayed prescription is a reasonable option 4
Antibiotic Therapy (When Indicated)
If antibiotics are prescribed, penicillin V is the first-choice agent, given twice or three times daily for 10 days 1, 2
- There is currently insufficient evidence to support shorter treatment durations 1
- For penicillin-allergic patients, clarithromycin is an acceptable alternative 6, 4
- First-generation cephalosporins, clindamycin, or macrolides can also be used in penicillin allergy 6
Amoxicillin Dosing (Alternative to Penicillin V)
For adults with ear/nose/throat infections: 7
- Mild/moderate: 500 mg every 12 hours or 250 mg every 8 hours
- Severe: 875 mg every 12 hours or 500 mg every 8 hours
- Treatment duration: minimum 10 days for Streptococcus pyogenes to prevent acute rheumatic fever 7
What NOT to Use
- Zinc gluconate is NOT recommended for sore throat treatment 1, 2
- Herbal treatments and acupuncture have inconsistent evidence and should not be routinely recommended 1, 2
- Local antibiotics or antiseptics lack efficiency data and should not be recommended 5
- Corticosteroids are NOT routinely recommended, though they can be considered in adult patients with severe presentations (3-4 Centor criteria) in conjunction with antibiotics 1, 2
Critical Clinical Pitfalls to Avoid
Misconceptions About Antibiotic Benefits
- Antibiotics do NOT prevent suppurative complications (quinsy, acute otitis media, sinusitis, mastoiditis) in most cases 1, 2
- The number needed to treat to prevent one case of quinsy is 27 or higher, and in modern primary care settings ranges from 50-200 1
- Antibiotics should NOT be used to prevent rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous rheumatic fever history) 1, 2
- These non-suppurative complications are extremely rare in the Western world in the 21st century 1
Duration and Natural History
- Most acute sore throats are self-limiting with a mean duration of 7 days regardless of treatment 4
- Treatment should continue for minimum 48-72 hours beyond symptom resolution or evidence of bacterial eradication 7
- The majority of throat infections are viral and resolve without antibiotic treatment 8