What are the steps for managing a sore throat?

Sore Throat Management

Most sore throats should be managed with ibuprofen or paracetamol for symptom relief, without antibiotics, unless the patient has 3-4 Centor criteria indicating high likelihood of streptococcal infection. 1, 2

Initial Assessment: Rule Out Red Flags

Before proceeding with routine management, immediately evaluate for life-threatening conditions requiring urgent intervention 3, 2:

• Severe refractory symptoms with difficulty swallowing, drooling, or "hot potato voice" suggesting peritonsillar or retropharyngeal abscess 3, 4
• Trismus or neck swelling/tenderness indicating possible deep space infection 4
• Signs of epiglottitis (cherry-red epiglottis, severe respiratory distress) 5, 6
• Lemierre syndrome in adolescents/young adults with severe pharyngitis 4, 2
• Immunosuppression requiring different management approach 3, 7

If any red flags are present, arrange urgent imaging and specialist consultation rather than empiric outpatient management 4.

Risk Stratification Using Centor Criteria

Apply the Centor scoring system to determine likelihood of group A streptococcal infection 1, 2:

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

Score 0-2 (Low Risk)

• Do NOT use antibiotics - these patients have viral pharyngitis 1, 2
• Do NOT perform rapid antigen testing or throat culture - testing is not routinely needed 1
• Proceed directly to symptomatic treatment 1, 7

Score 3-4 (High Risk)

• Consider rapid antigen detection test (RADT) to confirm streptococcal infection 1, 2
• Throat culture is NOT necessary after negative RADT in both children and adults 1
• Discuss with patient that antibiotic benefits are modest (shortening symptoms by only 1-2 days) and must be weighed against side effects, antimicrobial resistance, and costs 1, 2

Symptomatic Treatment (All Patients)

First-Line Analgesics

Ibuprofen is the recommended first-line medication for sore throat pain relief 3, 2:

• Provides effective pain control with low risk of adverse effects 3
• Safe when used according to directions for short-term treatment 3

Paracetamol (acetaminophen) is an effective alternative when ibuprofen is contraindicated or not tolerated 1, 3, 2:

• Strong evidence supports its use for sore throat pain 3
• Equally safe for short-term use 3

Additional Symptomatic Options

• Local anesthetics (lidocaine, benzocaine, ambroxol) as lozenges, throat sprays, or gargles may provide additional relief 3
• Adequate hydration with cool liquids 4

What NOT to Use

• Do NOT recommend local antibiotics or antiseptics - lack efficacy data and most sore throats are viral 3
• Do NOT use zinc gluconate - conflicting efficacy results with increased adverse effects 1, 3, 2
• Do NOT recommend herbal remedies or acupuncture - inconsistent evidence and lack of reliable efficacy data 1, 3, 2

Antibiotic Therapy (When Indicated)

Indications for Antibiotics

Antibiotics should be considered ONLY in patients with 1, 2:

• 3-4 Centor criteria AND
• Confirmed group A streptococcus by RADT or culture (if testing performed)

First-Line Antibiotic Choice

Penicillin V is the first-choice antibiotic when treatment is indicated 1, 2:

• Dose: twice or three times daily for 10 days 4, 2
• Clarithromycin serves as an alternative for penicillin-allergic patients 7

What Antibiotics Do NOT Prevent

Antibiotics should NOT be prescribed to prevent 1:

• Rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous rheumatic fever history)
• Suppurative complications (quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis) - these are not specific indications

Patient Education and Expectations

Reassure patients that typical sore throat duration is less than one week even without antibiotics 2, 7:

• Most cases (>65%) are viral and self-limiting 2
• Even bacterial infections often resolve just as quickly without antibiotics 8

Address patient expectations directly through structured communication 8:

• Elicit their concerns and opinions about antibiotics
• Explain that severity and complication risk matter more than bacterial vs. viral cause
• Provide written information on self-management options
• Empower patients to manage their condition confidently

Common Pitfalls to Avoid

• Do NOT treat every organism isolated from throat culture - E. coli and other colonizers are not pharyngeal pathogens and should not be treated 4
• Do NOT use broad-spectrum antibiotics empirically without confirming bacterial pathogen 4
• Do NOT routinely use biomarkers (C-reactive protein, procalcitonin) in assessment of acute sore throat 1
• Do NOT prescribe antibiotics based solely on patient pressure - use clinical scores and testing to guide decisions 8