Treatment for a 5-Day Sore Throat
For a sore throat lasting 5 days, start with ibuprofen or paracetamol for symptomatic relief, and only consider antibiotics if there is high clinical suspicion for Group A Streptococcal infection (3-4 Centor criteria) confirmed by rapid antigen testing. 1
Symptomatic Treatment (First-Line for All Patients)
Ibuprofen or paracetamol are the recommended first-line treatments for acute sore throat symptoms, with strong evidence supporting their efficacy in reducing pain and inflammation 1.
These analgesics reduce throat soreness, headache, and fever by approximately half, with maximal effect around day 3-4 of illness 2, 3.
Ibuprofen appears to have the best benefit-risk profile among available symptomatic treatments 4.
Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg lozenges) can be added for additional symptom relief 4.
When to Consider Antibiotics
Use clinical scoring to determine antibiotic need:
Low risk (0-2 Centor criteria): Do NOT prescribe antibiotics - the sore throat is likely viral and self-limiting 1, 5, 6.
Moderate risk (3 Centor criteria): Consider delayed antibiotic prescription - give the prescription but advise the patient to wait 2-3 days before filling it if symptoms don't improve 1, 5.
High risk (3-4 Centor criteria): Perform rapid antigen testing before prescribing antibiotics 1, 6.
Centor Criteria (1 point each):
- Fever (temperature >38°C)
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy
- Absence of cough 6
Antibiotic Treatment (If Indicated)
If antibiotics are warranted based on positive testing or high clinical suspicion:
Penicillin V is the first-line antibiotic: 250 mg twice or three times daily for 10 days in children; 250 mg four times daily or 500 mg twice daily for 10 days in adults 1, 7, 6.
Amoxicillin is an equally effective alternative: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg) for 10 days 7.
The full 10-day course is essential to achieve maximal bacterial eradication and prevent complications, particularly acute rheumatic fever 7, 8, 9.
For Penicillin-Allergic Patients:
Non-anaphylactic allergy: First-generation cephalosporins (cephalexin 20 mg/kg/dose twice daily or cefadroxil 30 mg/kg once daily for 10 days) 7, 8, 9.
Anaphylactic/immediate allergy: Clindamycin 7 mg/kg/dose three times daily (maximum 300 mg/dose) for 10 days is preferred over macrolides due to lower resistance rates (~1% vs 5-8%) 7, 8, 9.
Azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days) is acceptable but has higher resistance rates and should be reserved for patients who cannot tolerate other alternatives 7, 8, 10.
Important Context About Antibiotic Benefits
Antibiotics provide modest symptom reduction: They shorten symptom duration by approximately 16 hours overall and reduce sore throat at day 3 by about 30% 2, 3.
By one week, 82-90% of patients are symptom-free regardless of antibiotic use 2, 3.
The number needed to treat to prevent one sore throat at day 3 is approximately 5-6 patients; at one week it increases to 14-18 patients 2, 3.
Prevention of Complications
Antibiotics reduce suppurative complications: acute otitis media by 79% (Peto OR 0.21), quinsy by 84% (Peto OR 0.16) 3.
Antibiotics reduce acute rheumatic fever by 64% (Peto OR 0.36), though the baseline risk is extremely low in modern Western societies 2, 3.
The prevention of suppurative complications is NOT a specific indication for routine antibiotic therapy in sore throat given the low baseline rates in developed countries 1.
Corticosteroids
Corticosteroids are NOT routinely recommended for sore throat treatment 1, 8.
They may be considered in adults with severe presentations (3-4 Centor criteria) in conjunction with antibiotics, but evidence shows smaller effects in typical primary care populations 1.
No benefit has been demonstrated in children 1.
Common Pitfalls to Avoid
Do not prescribe antibiotics for low-risk patients (0-2 Centor criteria) - this contributes to antimicrobial resistance without meaningful benefit 1, 5, 6.
Do not shorten antibiotic courses below 10 days (except azithromycin's 5-day regimen) - this increases treatment failure rates and risk of complications 7, 8, 9.
Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions due to up to 10% cross-reactivity risk 8, 9.
Do not routinely perform follow-up throat cultures in asymptomatic patients who have completed therapy 8.
When to Reevaluate
- Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after starting treatment should be reevaluated for complications or alternative diagnoses 6.