What is the best practice for managing a sore throat?

Best Practice for Managing Sore Throat

Either ibuprofen or paracetamol (acetaminophen) are the recommended first-line treatments for acute sore throat, with ibuprofen showing slightly superior pain relief efficacy. 1, 2

Symptomatic Treatment Algorithm

First-Line Analgesics

• Ibuprofen is the preferred systemic analgesic for acute pharyngitis due to slightly better efficacy than paracetamol, particularly after 2 hours of administration. 2
• Paracetamol serves as an equally safe alternative when ibuprofen is contraindicated. 1, 2
• Both medications demonstrate excellent safety profiles for short-term use when following standard contraindications. 1
• Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg lozenges) can be added for additional symptomatic relief, with ambroxol having the best documented benefit-risk profile. 3

What NOT to Use

• Do not recommend local antibiotics or antiseptics - these lack efficacy data and are inappropriate given the predominantly viral etiology. 2, 3
• Zinc gluconate is not recommended due to conflicting efficacy results and increased adverse effects. 2
• Herbal remedies and acupuncture should not be recommended due to lack of reliable efficacy data. 2

Risk Stratification for Antibiotic Consideration

Apply Clinical Scoring (Centor Criteria)

• Fever (temperature >38°C)
• Absence of cough
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy 2, 4, 5

Antibiotic Decision Algorithm

Score 0-2 (Low Risk):

• Do NOT prescribe antibiotics - treat symptomatically with ibuprofen or paracetamol only. 2, 6
• Approximately 82% of patients are symptom-free by one week without antibiotics. 7

Score 3 (Moderate Risk):

• Consider delayed antibiotic prescription strategy. 5
• Discuss with patient that antibiotics only modestly reduce symptom duration (by 1-2 days) and must be weighed against side effects, antimicrobial resistance, and costs. 2, 6
• Rapid antigen detection test (RADT) can help guide decision if result will influence management. 4, 8

Score 4 (High Risk):

• Consider immediate antibiotic therapy after discussing modest benefits versus risks. 2, 5
• RADT should be performed before prescribing when feasible. 4

Antibiotic Selection When Indicated

First-Line Choice

• Penicillin V is the first-choice antibiotic: twice or three times daily for 5-7 days (some guidelines recommend 10 days). 2, 6, 5
• Penicillin V is preferred due to proven efficacy, safety, narrow spectrum, and low cost. 6

Alternative Options

• Amoxicillin is acceptable, particularly in younger children due to better taste and syrup availability. 6
• For penicillin-allergic patients: first-generation cephalosporins, clindamycin, or macrolides (clarithromycin). 4, 5

Special Situation

• Amoxicillin-clavulanate (40 mg/kg/day in 3 divided doses for 10 days) is specifically reserved for retreatment of patients with multiple repeated culture-positive episodes. 6

Corticosteroids - Limited Role

• Corticosteroids are NOT routinely recommended for sore throat treatment. 2
• Consider single low-dose oral dexamethasone (maximum 10 mg) ONLY in adults with severe presentations (Centor score 3-4) AND when used in conjunction with antibiotic therapy. 1, 2
• Do not use corticosteroids in patients with Centor score 0-2. 2

Pediatric Considerations

• Both ibuprofen and paracetamol are equally effective and safe in children with no significant difference in analgesic efficacy or safety. 1, 2
• The same risk stratification approach applies, though Centor criteria have lower utility in very young children. 6
• Most sore throats in toddlers are viral (part of common cold presentation). 6

Critical Pitfalls to Avoid

• Do not prescribe antibiotics to prevent complications in low-risk patients - the number needed to treat to prevent one sore throat at day 3 is less than 6, but at week 1 it increases to 18 due to natural resolution. 6, 7
• Recognize chronic GABHS carriers (10.9% in children ≤14 years, 2.3% in adults) who have intercurrent viral infections - they show extremely low risk of complications and do not require antibiotic treatment. 4
• Antimicrobial therapy is NOT indicated for chronic streptococcal carriers in most situations. 4
• The mean duration of acute sore throat is 7 days regardless of treatment - set appropriate patient expectations. 5

Red Flags Requiring Different Management

• Immunosuppression
• Severe systemic infection
• Peritonsillar abscess (quinsy): severe unilateral throat pain, trismus, uvular deviation, "hot potato voice" 4
• Lemierre's syndrome: persistent fever, neck pain, septic emboli 4
• Signs suggesting infectious mononucleosis: posterior cervical adenopathy, generalized lymphadenopathy, splenomegaly 4