What are the treatment options for a sore throat in an afebrile (without fever) patient?

From the Guidelines

For afebrile patients with sore throat, the primary approach should be symptomatic relief with over-the-counter pain relievers and throat lozenges, as antibiotics are not recommended unless there is confirmation of group A streptococcal pharyngitis. The management of sore throat, especially when the patient is afebrile, focuses on alleviating symptoms and improving quality of life, given that most cases are viral in nature and will resolve on their own. According to the guideline for the management of acute sore throat 1, either ibuprofen or paracetamol is recommended for relief of acute sore throat symptoms.

Symptomatic Relief Measures

• Gargling with warm salt water several times daily can help reduce throat discomfort.
• Staying well-hydrated with warm liquids is essential for soothing the throat and helping the body recover.
• Throat lozenges containing menthol or benzocaine can provide temporary pain relief.
• Over-the-counter pain relievers such as acetaminophen (325-650mg every 4-6 hours, not exceeding 3000mg daily) or ibuprofen (200-400mg every 4-6 hours with food, not exceeding 1200mg daily) can reduce throat pain and inflammation.
• Using a humidifier in the bedroom can add moisture to dry air that may be irritating the throat.
• Avoiding irritants like smoking, secondhand smoke, and alcohol is crucial for recovery and overall health.

Antibiotic Use

Antibiotics should only be considered if there is a confirmed diagnosis of group A streptococcal pharyngitis, as indicated by a rapid antigen detection test and/or culture for group A Streptococcus 1. The European Society for Clinical Microbiology and Infectious Diseases guideline suggests that in patients with a high likelihood of streptococcal infections (e.g., 3–4 Centor criteria), physicians can consider the use of rapid antigen test (RAT) 1. If antibiotics are indicated, penicillin V, twice or three times daily for 10 days, is recommended 1.

Monitoring and Follow-Up

Most viral sore throats resolve within 5-7 days with symptomatic relief measures. However, if symptoms persist beyond 7-10 days, worsen significantly, or if the patient develops difficulty swallowing, breathing problems, or unusual drooling, medical attention should be sought as these could indicate a bacterial infection like strep throat or a more serious condition requiring antibiotics or other treatment.

From the FDA Drug Label

Adults and Pediatric Patients Upper Respiratory Tract Infections of the Ear, Nose, and Throat:Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Streptococcusspecies. (α-and β-hemolytic isolates only), Streptococcus pneumoniae, Staphylococcusspp., or Haemophilus influenzae.

The treatment of sore throat when afebrile is not directly addressed in the provided drug label. However, the label does indicate that amoxicillin is used to treat upper respiratory tract infections, which may include sore throat, caused by susceptible bacteria.

• The dosage for mild/moderate ear/nose/throat infections is 500 mg every 12 hours or 250 mg every 8 hours for adults, and 25 mg/kg/day in divided doses every 12 hours or 20 mg/kg/day in divided doses every 8 hours for pediatric patients aged 3 months and older and weight less than 40 kg 2.
• It is recommended that treatment be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic, or evidence of bacterial eradication has been obtained.
• For infections caused by Streptococcus pyogenes, it is recommended that there be at least 10 days’ treatment to prevent the occurrence of acute rheumatic fever.

From the Research

Sore Throat Treatments when Afebrile

• The treatment of sore throat when afebrile (without fever) is primarily focused on symptomatic relief and reducing the risk of complications 3, 4.
• According to the German clinical practice guideline on sore throat, patients should be encouraged in self-management, and ibuprofen and naproxen are recommended for symptomatic treatment 3, 4.
• The use of antibiotics is generally not recommended for sore throat unless there is a high risk of bacterial pharyngitis, as determined by clinical scores such as the Centor, McIsaac, or FeverPAIN scores 3, 4.
• If antibiotics are considered, penicillin is the first choice, with clarithromycin as an alternative for those who do not tolerate penicillin, and the antibiotic should be taken for 5-7 days 3, 4.
• A systematic review of interventions for acute infective sore throat found that antibiotics, corticosteroids, non-steroidal anti-inflammatory drugs, and paracetamol may be effective in reducing symptoms, but the quality of evidence varies 5.
• The evaluation and management of adult pharyngitis involve assessing for fever, absence of cough, tender anterior cervical lymphadenopathy, and tonsillar swelling or exudate to identify those likely to have group A b-hemolytic streptococci (GABHS) 6.
• A critical analysis of current evidence and a consensus of experts from different countries and traditions recommend a new triage scheme considering both the acute risk for suppurative complications and sepsis as well as the long-term risk of developing rheumatic fever 7.