What is the treatment for a sore throat?

Treatment of Sore Throat

For acute sore throat, start with ibuprofen or paracetamol (acetaminophen) for symptomatic relief, and reserve antibiotics only for patients with high likelihood of bacterial infection (3-4 Centor criteria) after discussing the modest benefits versus risks. 1

First-Line Symptomatic Treatment

• Ibuprofen or paracetamol are the recommended first-line treatments for acute sore throat, with both showing equivalent efficacy and safety for short-term use 2, 1
• Ibuprofen appears to have slightly better efficacy than paracetamol for pain relief, particularly after 2 hours of administration 1
• Both medications carry a low risk of adverse effects when used according to directions for short-term treatment 1

Risk Stratification Using Centor Criteria

Before considering antibiotics, assess the patient using the Centor scoring system (1 point each for): 2, 1

• Fever (temperature >38.5°C)
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough

Treatment Algorithm Based on Centor Score:

0-2 Centor criteria (Low Risk):

• Do NOT use antibiotics - they provide no meaningful benefit and contribute to resistance, side effects, and unnecessary medicalization 2, 1
• Continue symptomatic treatment with ibuprofen or paracetamol 1
• No need for rapid antigen testing or throat culture 2

3-4 Centor criteria (High Risk):

• Consider antibiotics only after discussing modest benefits (1-2 days symptom reduction) versus risks with the patient 2
• Antibiotics reduce symptoms on day 3 (RR 0.72,95% CI 0.68-0.76) but provide only modest benefit at 1 week 2
• If antibiotics are indicated, penicillin V is the first choice: 500 mg twice or three times daily for 10 days 2, 3
• Amoxicillin is an acceptable alternative for upper respiratory tract infections due to susceptible Streptococcus species 3

What Antibiotics Do NOT Prevent

It is critical to understand the limitations of antibiotic therapy: 2

• Antibiotics should NOT be used to prevent rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous rheumatic fever history) - the absolute risk is extremely small in modern settings 2
• The number needed to treat to prevent one case of quinsy (peritonsillar abscess) is 27 or higher, reaching 50-200 in modern primary care settings 2
• Antibiotics do not reduce the incidence of acute sinusitis 2

Adjunctive Therapies

Corticosteroids:

• Not routinely recommended for sore throat treatment 2, 1
• Can be considered in adult patients with severe presentations (3-4 Centor criteria) when used in conjunction with antibiotic therapy 2, 1
• Use single low-dose oral dexamethasone (maximum 10 mg) if indicated 1

What NOT to Use

• Zinc gluconate is NOT recommended for sore throat treatment due to conflicting efficacy results and increased adverse effects 2, 1
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended (C-1 to C-3 evidence level) 2
• Local antibiotics or antiseptics are NOT recommended due to the mainly viral origin of most sore throats and lack of efficacy data 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on patient expectations or pressure - most sore throats are viral and self-limiting, resolving within 7 days 2, 4
• Do not use antibiotics in patients with 0-2 Centor criteria - even when rapid antigen testing is positive for Group A Streptococcus, the modest benefit does not outweigh the harms in low-risk presentations 2, 1
• Do not use the 875 mg dose of amoxicillin in patients with severe renal impairment (GFR <30 mL/min) 3
• Remember that even when antibiotics are indicated, they only hasten symptomatic improvement by 1-2 days in patients with confirmed Group A β-hemolytic streptococcal pharyngitis 2

Special Considerations

• Treatment should be continued for a minimum of 48-72 hours beyond symptom resolution or evidence of bacterial eradication 3
• For any infection caused by Streptococcus pyogenes, at least 10 days of treatment is recommended to prevent acute rheumatic fever 3
• In pediatric patients, both ibuprofen and paracetamol are effective with no significant difference in analgesic efficacy or safety 1