What treatment options are available for a persistent sore throat after using antihistamines, warm drinks, honey, and a Celestone (betamethasone) injection?

Treatment for Persistent Sore Throat After Initial Management

For a persistent sore throat that has not responded to antihistamines, warm drinks, honey, and a corticosteroid injection, the priority is symptomatic pain relief with ibuprofen or paracetamol, followed by clinical assessment using the Centor criteria to determine if antibiotics are warranted. 1

Immediate Next Steps: Optimize Symptomatic Treatment

The patient appears to have been treated for an allergic/rhinitis presentation rather than acute pharyngitis, which may explain the lack of response. The corticosteroid injection (Celestone/betamethasone) was likely inappropriate, as corticosteroids are not routinely recommended for sore throat treatment and should only be considered in severe presentations (3-4 Centor criteria) when given alongside antibiotics—not as monotherapy. 1

First-Line Symptomatic Management

• Either ibuprofen or paracetamol (acetaminophen) are the recommended first-line treatments for acute sore throat symptoms, with both showing equivalent efficacy. 1, 2
• Patients often do not use these medications correctly—they must be taken regularly (not as needed) at appropriate doses to achieve effective pain relief. 3
• Many patients underestimate the effectiveness of paracetamol because they use it sporadically rather than on a scheduled basis. 3

What NOT to Continue

• Antihistamines have a limited role in treating sore throat unless there is clear evidence of allergic rhinitis with postnasal drainage. 1 The fact that multiple antihistamines have failed suggests this is not primarily an allergic condition.
• Honey and warm drinks provide comfort but are not evidence-based treatments for acute pharyngitis. 1

Clinical Assessment: Determine Need for Antibiotics

Apply Centor Criteria

The Centor scoring system should guide antibiotic decision-making, assessing four features (1 point each): 1, 2, 4

• Fever (temperature >38°C)
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough

Interpretation and Management:

• 0-2 Centor criteria: Do NOT prescribe antibiotics. The presentation is too mild, and antibiotics provide no meaningful benefit for symptom relief or complication prevention. 1, 2
• 3-4 Centor criteria: Consider antibiotics only after discussing the modest benefits (symptom reduction by 1-2 days) versus risks including side effects, antimicrobial resistance, and costs. 1, 5, 4

If Antibiotics Are Indicated

• Penicillin V, given twice or three times daily for 10 days, is the first-choice antibiotic. 1, 2, 5, 4
• There is insufficient evidence to support shorter treatment durations. 1
• For penicillin-allergic patients, first-generation cephalosporins, clindamycin, or macrolides are acceptable alternatives. 4, 6

Critical Pitfalls to Avoid

What Antibiotics Do NOT Accomplish

• Antibiotics do not prevent suppurative complications (peritonsillar abscess, otitis media, sinusitis, mastoiditis) in most cases of acute sore throat. 1, 2, 5
• Antibiotics do not prevent rheumatic fever or acute glomerulonephritis in low-risk patients without prior rheumatic fever history. 1, 2, 5, 4
• Even when bacterial infection is confirmed, antibiotics only modestly shorten symptom duration and must be weighed against harms. 1, 5

Inappropriate Treatments

• Zinc gluconate is not recommended for sore throat treatment. 1, 2
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended. 1, 2
• Systemic corticosteroids alone (like the Celestone injection already given) are not routinely recommended and should only be considered in severe presentations when combined with antibiotics. 1

When to Suspect Alternative Diagnoses

If symptoms persist beyond 7-14 days despite appropriate management, consider: 4, 7

• Infectious mononucleosis (Epstein-Barr virus): Look for posterior cervical lymphadenopathy, generalized lymphadenopathy, and splenomegaly. 4
• Peritonsillar abscess: Severe unilateral throat pain, trismus, uvular deviation, and "hot potato voice." 4
• Gastroesophageal reflux disease (GERD): Chronic throat irritation without acute infectious features. 4
• Chronic streptococcal carrier state with intercurrent viral infection: These patients (10.9% of children, 2.3% of adults) have positive throat cultures but are experiencing viral pharyngitis. 4

Practical Algorithm

1. Ensure adequate scheduled dosing of ibuprofen or paracetamol (not as-needed dosing). 1, 2, 3
2. Calculate Centor score based on clinical examination. 1, 2, 4
3. If 0-2 criteria: Reassure, continue symptomatic treatment, expect resolution within 7 days. 1, 2, 7
4. If 3-4 criteria: Discuss antibiotic benefits/risks; if patient agrees, prescribe penicillin V for 10 days. 1, 2, 5
5. If symptoms persist >14 days or red flags develop: Re-evaluate for alternative diagnoses. 4, 8