What is the treatment for a sore throat?

Treatment of Sore Throat

Start with ibuprofen or paracetamol for symptomatic relief in all patients with acute sore throat, and reserve antibiotics only for those with high likelihood of Group A streptococcal infection (3-4 Centor criteria) after discussing modest benefits versus risks. 1, 2

First-Line Symptomatic Treatment

• Ibuprofen is the preferred first-line analgesic as it demonstrates slightly superior efficacy compared to paracetamol, particularly for pain relief after 2 hours of administration 2, 3
• Paracetamol serves as an effective alternative when ibuprofen is contraindicated or not tolerated 1, 2
• Both medications carry low risk of adverse effects when used according to directions for short-term treatment 2, 3
• Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg) can be added as lozenges, throat sprays, or gargles for additional symptomatic relief 3, 4

Risk Stratification Using Centor Criteria

Use the Centor score to determine antibiotic necessity:

• 0-2 Centor criteria (low risk): Do NOT prescribe antibiotics; symptomatic treatment with ibuprofen or paracetamol is sufficient 1, 2
• 3-4 Centor criteria (high risk): Consider antibiotics after discussing the modest benefits (symptom reduction of approximately 16 hours) against risks including side effects, microbiota disruption, antimicrobial resistance, and costs 1, 2

The Centor criteria include: tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever 1

Antibiotic Selection When Indicated

• Penicillin V is the first-choice antibiotic when treatment is warranted, dosed twice or three times daily for 10 days 1
• Amoxicillin is an acceptable alternative for upper respiratory tract infections due to susceptible (β-lactamase-negative) Streptococcus species 5
• For adults with ear/nose/throat infections: 500 mg every 12 hours or 250 mg every 8 hours for mild/moderate cases; 875 mg every 12 hours or 500 mg every 8 hours for severe cases 5
• Treatment duration should be at least 10 days for any infection caused by Streptococcus pyogenes to prevent acute rheumatic fever 5

Diagnostic Testing Strategy

• Rapid antigen detection tests (RATs) should be considered in patients with 3-4 Centor criteria 1
• A negative RAT in adults is sufficient to rule out streptococcal pharyngitis—no confirmatory throat culture is needed 1
• Do NOT routinely use RATs in patients with 0-2 Centor criteria as the likelihood of bacterial infection is too low to justify testing 1
• Throat culture is not necessary for routine diagnosis of acute sore throat 1
• Biomarkers (C-reactive protein, procalcitonin) are not necessary in routine assessment 1

Corticosteroid Use (Limited Role)

• Corticosteroids are NOT routinely recommended for sore throat treatment 1, 2
• Consider a single dose of corticosteroids in conjunction with antibiotic therapy ONLY in adults with severe presentations (3-4 Centor criteria) 1, 2
• The effect is modest and smaller when administered orally versus parenterally 1
• No evidence of significant benefit in children 1

What NOT to Use

• Do NOT recommend local antibiotics or antiseptics—most sore throats are viral and these lack efficacy data 2, 3, 6, 4
• Do NOT use zinc gluconate—conflicting efficacy results and increased adverse effects make this inappropriate 1, 2, 6
• Do NOT recommend herbal treatments or acupuncture—inconsistent evidence and lack of reliable efficacy data 1, 2, 6

Critical Antibiotic Stewardship Points

• Antibiotics do NOT prevent rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous history of rheumatic fever) 1
• Prevention of suppurative complications (quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis) is NOT a specific indication for antibiotic therapy 1
• Most cases of acute sore throat are viral and self-limiting with mean duration of 7 days 7
• Prescribing antibiotics empirically without testing drives antimicrobial resistance and provides no benefit in viral pharyngitis 6, 7

Common Pitfalls to Avoid

• Do not assume all throat pain requires antibiotics—the vast majority of cases are self-limiting viral infections 6, 7, 8
• Do not ignore the high rate of asymptomatic streptococcal carriage (>20% in school children), which can lead to false-positive tests and unnecessary antibiotic use 1
• Do not prescribe antibiotics based on clinical symptoms alone without risk stratification or laboratory confirmation 6, 9
• Ensure red flags are excluded before initiating symptomatic treatment: severe refractory symptoms, immunosuppression, signs of abscess, epiglottitis, or Lemierre syndrome 3, 8