Treatment for Sore Throat
Most sore throats should be treated with ibuprofen or paracetamol for symptom relief, and antibiotics should NOT be used unless the patient has severe presentation (3-4 Centor criteria) with confirmed or highly suspected Group A streptococcal infection. 1
First-Line Symptomatic Treatment
Either ibuprofen or paracetamol are recommended as first-line therapy for acute sore throat symptoms. 1
- Both medications show equivalent efficacy and safety for short-term use 2, 3, 4
- Ibuprofen appears to have slightly better efficacy for pain relief, particularly after 2 hours of administration 3, 5
- In a head-to-head trial, 400 mg ibuprofen was more effective than 1000 mg acetaminophen on all rating scales at all time points after 2 hours 5
- For patients with renal impairment, paracetamol is the safer choice due to NSAID risks 2
When to Consider Antibiotics: Use the Centor Criteria
Antibiotics should NOT be routinely prescribed for sore throat. The decision depends on clinical severity using Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough): 1, 2
Centor Score 0-2 (Mild Presentation)
- Do NOT prescribe antibiotics 1
- Antibiotics provide no meaningful benefit for symptom relief 1
- No need for rapid antigen testing or throat culture 1
- Continue symptomatic treatment with ibuprofen or paracetamol 1
Centor Score 3-4 (Severe Presentation)
- Consider antibiotics only after discussing modest benefits versus risks with the patient 1
- Antibiotics provide only 1-2 days of symptom reduction 1
- Benefits must be weighed against side effects, antimicrobial resistance, impact on microbiota, and costs 1
- Rapid antigen testing can be considered to guide decision-making 1
- Delayed prescribing (waiting 48+ hours) is a valid option with no difference in complication rates 1, 6
Antibiotic Choice (If Indicated)
If antibiotics are prescribed, penicillin V is the first-choice agent, given twice or three times daily for 10 days. 1, 2
- Penicillin V remains the treatment of choice due to proven efficacy, safety, narrow spectrum, and low cost 1
- Group A streptococci have not developed resistance to penicillin over five decades 1
- Although cephalosporins show statistically better cure rates, the clinical difference is small and not clinically relevant 1
- There is insufficient evidence to support shorter treatment durations 1
- For penicillin allergy, clarithromycin is an alternative 6, 7
What Antibiotics Do NOT Prevent
Critical pitfall: Antibiotics do NOT prevent most complications in low-risk patients. 1
- Antibiotics do NOT prevent suppurative complications (quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis) in most cases 1, 2
- Antibiotics do NOT prevent rheumatic fever or acute glomerulonephritis in low-risk patients without prior rheumatic fever history 1, 2
- Prevention of complications is NOT a specific indication for antibiotic therapy 1
Adjunctive Therapies
Corticosteroids
- NOT routinely recommended 1, 3
- Can be considered in adult patients with severe presentations (3-4 Centor criteria) in conjunction with antibiotic therapy 1, 3
- Use single low-dose oral dexamethasone (maximum 10 mg) if prescribed 3
What NOT to Use
- Zinc gluconate is NOT recommended for sore throat treatment 1, 2, 3, 4
- Herbal treatments and acupuncture have inconsistent evidence and should not be recommended 1, 2, 3, 4
- Local antibiotics or antiseptics should NOT be used due to mainly viral origin and lack of efficacy data 3, 8
Clinical Algorithm Summary
Assess severity using Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) 1, 2
Start symptomatic treatment immediately: Ibuprofen or paracetamol 1, 2, 3, 4
For Centor 0-2: No antibiotics, no testing, continue symptomatic treatment 1
For Centor 3-4: Discuss risks/benefits with patient, consider delayed prescribing, if antibiotics chosen use penicillin V for 10 days 1, 2
Reassess if symptoms persist beyond 7 days (typical self-limiting duration) 6