What is the recommended approach for a throat examination and treatment of throat infections?

Throat Examination and Treatment Approach

Use the Centor clinical scoring system to guide your examination and testing strategy, reserving antibiotics only for patients with 3-4 Centor criteria, and when antibiotics are indicated, prescribe penicillin V for 10 days as first-line therapy. 1

Physical Examination Technique

When examining the throat, focus on these specific findings:

• Swab both sides of the posterior pharynx and the uvula using a throat swab, avoiding contact with the tongue or buccal mucosa 1
• Look for erythema and edema of the pharynx, tonsils, and uvula, with or without exudate 1
• Assess for cervical lymphadenopathy (tender anterior cervical nodes) 2
• Document temperature (fever >38.3°C suggests bacterial infection) 1
• Note absence of viral features such as cough, rhinorrhea, hoarseness, or oral ulcers, which strongly suggest viral etiology 1

Diagnostic Strategy Using Centor Criteria

The Centor score assigns one point for each of the following 1:

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

For patients with 0-2 Centor criteria:

• Do not test or treat with antibiotics 1
• Provide symptomatic treatment only 1

For patients with 3-4 Centor criteria:

• Perform rapid antigen detection test (RADT) 1
• If RADT is positive, no backup culture is needed due to high specificity 1
• In children and adolescents, backup negative RADTs with throat culture 1
• In adults, backup cultures for negative RADTs are not routinely necessary due to low rheumatic fever risk 1

Important Diagnostic Pitfalls

• Do not test children under 3 years old routinely, as streptococcal pharyngitis and rheumatic fever are uncommon in this age group 1
• Do not use anti-streptococcal antibody titers for acute diagnosis, as they reflect past rather than current infection 1
• Do not test or treat asymptomatic household contacts routinely 1

Treatment Recommendations

Symptomatic Management (All Patients)

• Prescribe ibuprofen or paracetamol for pain relief 1
• Do not recommend zinc gluconate, as evidence does not support its use 1
• Herbal treatments and acupuncture have inconsistent evidence 1

Antibiotic Therapy (When Indicated)

First-line treatment:

• Penicillin V, 2-3 times daily for 10 days is the drug of choice due to proven efficacy, safety, narrow spectrum, and low cost 1
• Amoxicillin is an acceptable alternative, particularly in young children due to better palatability 1, 3

For penicillin-allergic patients:

• First-generation cephalosporins 1
• Erythromycin 2
• Clindamycin 1

Critical Treatment Principles

• The modest benefits of antibiotics (reducing symptoms by approximately 1-2 days) must be weighed against side effects, impact on microbiota, increased resistance, medicalisation, and costs 1
• Prevention of suppurative complications is not a specific indication for antibiotic therapy in routine sore throat 1
• Antibiotics reduce acute rheumatic fever to less than one-third (though this is rare in modern Western societies) 4
• Do not perform routine post-treatment cultures in asymptomatic patients 1

Special Circumstances

For recurrent culture-positive episodes:

• Consider amoxicillin-clavulanate 40 mg/kg/day in 3 divided doses for 10 days for retreatment 5
• This broader-spectrum option should be reserved for specific retreatment scenarios, not first-line therapy 5

Watchful waiting is appropriate for recurrent infections with <7 episodes in the past year, <5 episodes per year for 2 years, or <3 episodes per year for 3 years 5, 6

Common Clinical Pitfalls to Avoid

• Do not use broad-spectrum antibiotics like amoxicillin-clavulanate as first-line therapy, as this increases resistance without additional clinical benefit 5
• Do not treat based on clinical features alone without considering Centor criteria or testing, except when obvious viral features are present 1
• Do not initiate antibiotics in patients with 0-2 Centor criteria, as most cases are viral and self-limited 1, 7
• Most untreated sore throats resolve within 7 days regardless of etiology 7, 4