How do I treat a sore throat?

How to Treat a Sore Throat

For most patients with acute sore throat, start with ibuprofen or paracetamol (acetaminophen) for symptom relief and avoid antibiotics unless the patient has severe presentation with 3-4 Centor criteria AND positive streptococcal testing. 1

First-Line Symptomatic Treatment

Either ibuprofen or paracetamol are recommended as first-line treatments for acute sore throat pain relief. 2, 1 Both medications demonstrate equivalent efficacy and safety for short-term use, though ibuprofen shows slightly better pain relief particularly after 2 hours of administration. 1 The risk of adverse effects is low when used according to directions for short-term treatment. 1

• Ibuprofen dosing: 400-600 mg every 6-8 hours as needed 3
• Paracetamol dosing: 500-1000 mg every 6 hours as needed 3

Determining Who Needs Antibiotics: Use Centor Criteria

The decision to use antibiotics depends on clinical severity assessed by Centor scoring, which includes: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 1, 4

Centor Score 0-2 (Low Risk)

• Do NOT use antibiotics - they provide no meaningful benefit for symptom relief in this group 2, 1, 4
• Do NOT perform rapid antigen testing or throat culture - testing is not routinely indicated 3
• Treat symptomatically with analgesics only 2, 1

Centor Score 3-4 (High Risk)

• Consider rapid antigen testing (RAT) in patients with high likelihood of streptococcal infection 2
• If RAT is performed, throat culture is not necessary after a negative RAT 2
• Discuss modest benefits versus risks with the patient before prescribing antibiotics 2, 4
• The benefits are modest and must be weighed against side effects, impact on microbiota, antibiotic resistance, medicalization, and costs 2, 1

When Antibiotics Are Indicated: First-Choice Agent

If antibiotics are indicated based on positive testing in high-risk patients, penicillin V twice or three times daily for 10 days is recommended. 2, 1, 4 There is insufficient evidence supporting shorter treatment duration. 2

What Antibiotics Do NOT Prevent

Understanding the limitations of antibiotic therapy is critical to avoid overuse:

• 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 of these complications is extremely small in modern Western settings 2, 4
• Prevention of suppurative complications is NOT a specific indication for antibiotic therapy - the number needed to treat to prevent one case of quinsy is 27 or higher, and in modern primary care settings ranges from 50-200 2, 4
• Antibiotics do not reduce the incidence of acute sinusitis 2

Corticosteroids: Limited Role

Corticosteroids are NOT routinely recommended for sore throat treatment. 2, 1 However, they can be considered in adult patients with severe presentations (3-4 Centor criteria) when used in conjunction with antibiotic therapy. 2, 1 The effect of steroids is smaller when administered by oral route, and studies were not sufficiently powered to detect adverse effects of short courses. 2

What NOT to Use

Several treatments lack evidence or have been shown ineffective:

• Zinc gluconate is NOT recommended - trials provided conflicting results and patients in zinc groups had more adverse effects 2, 1, 4
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended - systematic reviews found methodologically poor quality studies with high risk of bias 2, 1, 4
• Local antibiotics or antiseptics are NOT recommended due to the mainly viral origin of most sore throats and lack of efficacy data 1

Special Considerations for Renal Impairment

For patients with renal impairment, paracetamol is the safer choice due to potential risks of NSAIDs like ibuprofen. 4 Paracetamol dosing does not require adjustment for mild-to-moderate renal impairment, though caution is warranted in severe cases. 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on patient expectations or pressure - most throat infections are viral and resolve without antibiotics 5
• Do not use antibiotics in patients with 0-2 Centor criteria even if they request them - this contributes to resistance without providing benefit 2, 1, 3
• Do not assume bacterial infection requires antibiotics - even many bacterial throat infections resolve just as quickly without antibiotics 5
• Maintain high index of suspicion for serious pathology such as epiglottitis, retropharyngeal abscess, or peritonsillar abscess in patients with severe symptoms, unilateral tonsillar swelling, difficulty breathing or swallowing, drooling, or muffled voice 3, 6