What is the management for severe sore throat in influenza?

Management of Severe Sore Throat in Influenza

For severe sore throat in influenza, prioritize symptomatic relief with ibuprofen or paracetamol, initiate oseltamivir 75 mg twice daily for 5 days if within 48 hours of symptom onset, and reserve antibiotics only for patients who develop pneumonia or are at high risk with worsening lower respiratory symptoms. 1, 2

Symptomatic Management

• Administer either ibuprofen or paracetamol as first-line analgesics for sore throat pain relief, as both are equally effective for acute pharyngeal symptoms in influenza. 1

• Avoid aspirin in children and adolescents with influenza due to the risk of Reye syndrome. 2

• Ensure adequate hydration and supportive care measures while monitoring for clinical deterioration. 1

Antiviral Therapy Decision Framework

Initiate oseltamivir if ALL of the following criteria are met:

• Acute influenza-like illness with fever >38°C in adults (>38.5°C in children) 1
• Symptomatic for ≤48 hours 1, 2
• Dosing: 75 mg orally twice daily for 5 days (reduce to 75 mg once daily if creatinine clearance <30 mL/min) 1

Important exceptions where antiviral therapy should still be considered despite lack of fever or delayed presentation:

• Immunocompromised or very elderly patients who may not mount adequate febrile response 1
• Severely ill hospitalized patients, even if presenting >48 hours after symptom onset 1
• Patients on long-term corticosteroid therapy 1

Antibiotic Decision Algorithm

DO NOT routinely prescribe antibiotics for:

• Previously well adults with influenza and sore throat/acute bronchitis in the absence of pneumonia 1, 2
• Uncomplicated influenza with isolated pharyngeal symptoms 3, 2

CONSIDER antibiotics when:

• Previously well patients develop worsening symptoms such as recrudescent fever or increasing dyspnea 1
• High-risk patients (elderly, chronic cardiac/respiratory disease, immunocompromised) develop any lower respiratory tract features, even without confirmed pneumonia 1, 3

IMMEDIATELY initiate antibiotics for:

• Any confirmed or suspected influenza-related pneumonia (radiographic evidence or clinical diagnosis) 3, 2
• Antibiotics must be administered within 4 hours of hospital admission for pneumonia cases 1, 3

Antibiotic Regimens for Influenza-Related Pneumonia

Non-Severe Pneumonia:

• First-line oral: Co-amoxiclav OR tetracycline (doxycycline 100 mg once daily if >12 years) 1, 3
• Alternative (penicillin allergy): Macrolide (clarithromycin or erythromycin) OR respiratory fluoroquinolone (levofloxacin or moxifloxacin) with activity against S. pneumoniae and S. aureus 1, 3
• Duration: 7 days for uncomplicated cases 1, 3

Severe Pneumonia:

• Immediate IV combination therapy required: Broad-spectrum beta-lactamase stable antibiotic (co-amoxiclav OR cefuroxime OR cefotaxime) PLUS IV macrolide (clarithromycin or erythromycin) 1, 3, 2
• Alternative combination: Respiratory fluoroquinolone (levofloxacin IV) PLUS broad-spectrum beta-lactamase stable antibiotic OR macrolide 1, 3
• Duration: 10 days for severe, microbiologically undefined pneumonia; extend to 14-21 days if S. aureus or gram-negative enteric bacilli suspected or confirmed 1, 3
• Transition to oral: Switch when clinical improvement occurs and temperature normal for 24 hours 1, 3

Critical Pitfalls to Avoid

• Never delay antiviral treatment while awaiting laboratory confirmation—clinical diagnosis of influenza is sufficient, and treatment within 24 hours provides maximum benefit. 2

• Do not prescribe antibiotics for uncomplicated influenza pharyngitis simply because the sore throat is "severe"—severity of pharyngeal pain alone does not indicate bacterial superinfection. 1, 2

• Remember that influenza-related pneumonia requires coverage for S. aureus in addition to typical community-acquired pneumonia pathogens, as bacterial co-infection is a major cause of influenza-associated mortality. 3, 2

• If empiric antibiotic therapy fails in non-severe pneumonia, switch to a fluoroquinolone with pneumococcal and staphylococcal coverage; for severe pneumonia not responding to combination therapy, add MRSA coverage (vancomycin or linezolid). 1, 3

• Corticosteroids are not routinely recommended for influenza-related sore throat, though they can be considered in conjunction with antibiotics for severe presentations (3-4 Centor criteria) in non-influenza bacterial pharyngitis contexts. 1