Treatment of Sore Throat with Congestion and Loss of Appetite
Start with ibuprofen or paracetamol (acetaminophen) for symptomatic relief, and do NOT prescribe antibiotics unless the patient has 3-4 Centor criteria after clinical assessment. 1, 2
Immediate Symptomatic Management
- Offer ibuprofen or paracetamol as first-line analgesic therapy to all patients with sore throat, with both showing equivalent efficacy and safety for short-term use. 1, 2, 3
- Ibuprofen shows slightly better efficacy for pain relief, particularly after 2 hours of administration, making it the preferred choice if no contraindications exist. 3
- Take medication at the start of a meal to minimize gastrointestinal intolerance. 4
- Reassure the patient that typical sore throat duration is less than one week, with most cases resolving within 7 days without antibiotics. 2, 5
Clinical Assessment Using Centor Criteria
Before considering antibiotics, assess the following four criteria (1 point each): 1, 2
- Fever (temperature >38°C)
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough
Scoring interpretation:
- 0-2 points: Do NOT prescribe antibiotics - the presentation is too mild and antibiotics provide no meaningful benefit. 1, 2, 3
- 3-4 points: Consider antibiotics only after discussing modest benefits versus risks - antibiotics shorten symptoms by only 1-2 days and must be weighed against side effects, antimicrobial resistance, and costs. 2, 3
Antibiotic Therapy (Only If 3-4 Centor Criteria Present)
- Penicillin V is the first-choice antibiotic, given twice or three times daily for 10 days. 1, 2, 3
- Amoxicillin is an acceptable alternative for upper respiratory tract infections due to susceptible Streptococcus species (β-lactamase-negative isolates only). 4
- Treatment should continue for at least 10 days for any Streptococcus pyogenes infection to prevent acute rheumatic fever. 4, 5
What NOT to Do
- Do not use zinc gluconate - it has conflicting efficacy results and increased adverse effects. 1, 2, 3
- Do not recommend herbal treatments or acupuncture - evidence is inconsistent and unreliable. 1, 2, 3
- Do not use local antibiotics or antiseptics - most sore throats are viral in origin (>65% of cases) and these agents lack efficacy data. 2, 3
- Do not routinely prescribe corticosteroids - they can only be considered in severe presentations (3-4 Centor criteria) when used in conjunction with antibiotics. 1, 3
Critical Clinical Pitfalls to Avoid
- Antibiotics do not prevent suppurative complications (quinsy, otitis media, sinusitis, mastoiditis) in most cases. 1
- Antibiotics do not prevent rheumatic fever or glomerulonephritis in low-risk patients without prior rheumatic fever history. 1
- Even when indicated, the benefit is modest - only 1-2 days of symptom reduction - which rarely justifies the risks of side effects and antimicrobial resistance. 2, 3
- Most throat infections (>65%) are viral and resolve without antibiotic treatment. 2, 6
Addressing Congestion and Loss of Appetite
- The congestion and loss of appetite suggest a viral upper respiratory infection, which further supports withholding antibiotics unless Centor criteria are met. 7, 8
- Continue symptomatic management with analgesics and encourage self-care measures. 5, 6
- Symptoms should improve within 48-72 hours with symptomatic treatment alone. 4, 5