What is the treatment for a sore throat with hyperpyrexia?

Treatment of Sore Throat with High Fever (103°F)

For a patient with 4 days of sore throat and high fever at 103°F, you should assess the Centor criteria immediately and consider antibiotics only if the score is 3-4 points, while providing symptomatic treatment with ibuprofen or acetaminophen regardless of bacterial likelihood. 1

Immediate Assessment: Apply Centor Criteria

Calculate the Centor score based on four clinical features 1:

• Fever by history (present in this case = 1 point)
• Tonsillar exudates (examine now)
• Tender anterior cervical adenopathy (examine now)
• Absence of cough (ask patient)

The high fever of 103°F (39.4°C) is concerning and warrants careful evaluation, but fever alone does not mandate antibiotics 1.

Risk Stratification Based on Centor Score

Low Risk (0-2 points): No Antibiotics Indicated

• Antibiotics should NOT be used in patients with 0-2 Centor criteria, as this represents likely viral pharyngitis 1
• The modest 1-2 day symptom reduction does not justify the side effects, antimicrobial resistance, and costs 1
• Provide symptomatic treatment only 1

Moderate Risk (3 points): Consider Delayed Prescription

• Discuss the modest benefits (1-2 days of symptom reduction) versus risks with the patient 1
• Delayed prescribing is a valid option - give prescription but instruct patient to fill only if symptoms worsen or persist beyond 48 hours 1
• Rapid antigen detection testing (RADT) can be considered to guide decision-making 1

High Risk (4 points): Antibiotics Can Be Started

• In patients with 3-4 Centor criteria, antibiotics provide modest benefit in Group A streptococcus-positive patients 1
• RADT is reasonable to confirm bacterial pharyngitis before starting antibiotics 1
• Even with high scores, antibiotics only hasten symptom improvement by 1-2 days 1

First-Line Antibiotic Choice (If Indicated)

Penicillin V is the first-choice antibiotic, given twice or three times daily for 10 days 1, 2:

• Proven efficacy over five decades 1
• Narrow spectrum minimizes resistance 1
• Low cost 1
• Group A streptococci have never developed resistance to penicillin 1

Amoxicillin is an acceptable alternative, particularly in younger children due to better taste and syrup availability 3, 2:

• Dosing: 500 mg every 12 hours or 250 mg every 8 hours for mild/moderate infections 2
• For severe infections: 875 mg every 12 hours or 500 mg every 8 hours 2
• Must treat for minimum 10 days to prevent rheumatic fever 2

Symptomatic Treatment (Always Provide)

Either ibuprofen or acetaminophen (paracetamol) are strongly recommended for pain and fever relief 1:

• These should be given regardless of whether antibiotics are prescribed 1
• Take at the start of meals to minimize gastrointestinal intolerance 2
• Continue for symptom control throughout the illness course 1

Red Flags Requiring Urgent Evaluation

Immediately evaluate for life-threatening complications if any of these are present 4:

• Difficulty swallowing or drooling (suggests peritonsillar or retropharyngeal abscess) 4
• Trismus (inability to open mouth) 4
• "Hot potato voice" (muffled voice quality) 4
• Unilateral tonsillar swelling with uvular deviation (peritonsillar abscess) 4
• Neck stiffness, tenderness, or swelling (retropharyngeal abscess) 4
• Stridor or respiratory distress (epiglottitis - airway emergency) 4, 5

These conditions require imaging and specialist consultation, not just empiric antibiotics 4.

Common Pitfalls to Avoid

Do not prescribe antibiotics to prevent rheumatic fever in low-risk patients (those without previous rheumatic fever history), as the absolute risk is extremely small in modern Western settings 1:

• Rheumatic fever prevention was only demonstrated in 1950s-1960s trials when rates were much higher 1
• Number needed to treat to prevent one case of peritonsillar abscess is 50-200 in modern practice 1

Do not use broad-spectrum antibiotics like amoxicillin-clavulanate as first-line therapy 3:

• Increases resistance without additional clinical benefit 3
• Reserve for specific indications like retreatment of recurrent culture-positive episodes 3

Do not start antibiotics immediately without assessment 1:

• Treatment within 2-3 days of symptom onset still provides benefit 1
• Delayed prescribing shows no difference in complication rates compared to immediate antibiotics 1

Do not assume high fever alone indicates bacterial infection 1, 6:

• Most sore throats (>65%) are viral, even with significant fever 6
• Clinical scoring systems are more predictive than fever alone 1

Expected Clinical Course

Most sore throats resolve within 7 days without antibiotics, even when bacterial 1, 6:

• Antibiotics reduce symptoms on day 3 (relative risk 0.72) but benefit diminishes by 1 week 1
• Continue treatment for minimum 48-72 hours beyond symptom resolution 2
• For any Group A streptococcal infection, treat for at least 10 days to prevent rheumatic fever 2