What is the appropriate management for a patient with fever, sore throat, and tachycardia, without cough or chest pain?

Management of Fever, Sore Throat, and Tachycardia

Test for Group A Streptococcus using rapid antigen detection test or throat culture before prescribing antibiotics, and treat with penicillin V 500 mg twice daily for 10 days only if the test is positive. 1

Immediate Assessment and Differential Diagnosis

The clinical presentation requires systematic evaluation to distinguish bacterial from viral pharyngitis, as this fundamentally determines management.

Key Clinical Features to Assess

• Fever of 101.5°F with heart rate of 143 bpm: The tachycardia is likely appropriate for the fever (expected heart rate increase of ~10 bpm per degree Fahrenheit above normal), but verify the patient is not dehydrated or developing a complication 2
• Absence of cough and chest pain: These features increase the likelihood of bacterial pharyngitis, as cough strongly suggests viral etiology 1, 3
• Look specifically for: tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of rhinorrhea or conjunctivitis 1, 4, 5

Apply the Centor/Modified Centor Score

Calculate the score based on:

• Fever history (1 point)
• Tonsillar exudates (1 point)
• Tender anterior cervical adenopathy (1 point)
• Absence of cough (1 point)
• Age 15-44 years (0 points) or Age ≥45 years (-1 point) 1, 3

If score is 0-1: No testing needed; viral pharyngitis is most likely 1, 6

If score is 2-3: Perform rapid antigen detection test (RADT) or throat culture 1, 3

If score is ≥4: High probability of Group A Streptococcus; perform RADT (positive result is diagnostic in adults and requires no backup culture) 1

Antibiotic Treatment (Only if GAS Confirmed)

First-Line Therapy

Penicillin V 500 mg orally twice daily for 10 days is the treatment of choice due to proven efficacy, narrow spectrum, safety, low cost, and zero documented resistance 1

• Alternative dosing: 250 mg three or four times daily for 10 days 1
• Amoxicillin 500 mg twice daily for 10 days is equally effective and may improve adherence due to better palatability 1, 3
• The full 10-day course is mandatory—shortening treatment increases risk of treatment failure and rheumatic fever 1

Penicillin Allergy Alternatives

• Non-anaphylactic allergy: Cephalexin 500 mg orally twice daily for 10 days (low cross-reactivity risk) 1
• Anaphylactic/immediate allergy: Clindamycin 300 mg orally three times daily for 10 days (high efficacy, low resistance) 1
• Alternative option: Azithromycin 500 mg once daily for 5 days (acceptable but not preferred due to 5-8% macrolide resistance rates) 1

Symptomatic Management (Regardless of Etiology)

Pain and Fever Control

• Ibuprofen or acetaminophen for throat pain and fever control 2, 1, 6
• NSAIDs (ibuprofen, naproxen) are recommended as first-line analgesics 2, 6
• Throat lozenges containing topical anesthetics (benzocaine, lidocaine) may provide temporary relief 2, 7

Supportive Measures

• Warm salt water gargles for patients able to gargle 7
• Adequate hydration with cool liquids 8
• Sleeping with head of bed elevated may improve comfort 7
• Warm facial packs and steamy showers for symptom relief 7

Critical Pitfalls to Avoid

Never prescribe antibiotics without confirming Group A Streptococcus infection—this leads to unnecessary antibiotic exposure, resistance development, and adverse effects without clinical benefit 1, 2

Never shorten the antibiotic course below 10 days (except azithromycin's 5-day regimen)—this increases treatment failure risk and rheumatic fever incidence 1

Do not use cephalosporins in patients with anaphylactic penicillin reactions due to 10% cross-reactivity risk 1

Do not assume all pharyngitis with fever requires antibiotics—more than 60% of adults with sore throat receive unnecessary antibiotic prescriptions, yet most cases are viral and self-limiting within 7 days 2, 8

Addressing the Tachycardia

• Heart rate of 143 bpm with temperature of 101.5°F is within expected range for fever-induced tachycardia 2
• Ensure adequate hydration and fever control with antipyretics 7
• If tachycardia persists after fever resolution or patient appears toxic, consider complications such as peritonsillar abscess or systemic infection requiring urgent evaluation 2

When to Escalate Care

Contact physician or seek urgent evaluation if: 7, 8

• Symptoms worsen or fail to improve within 3-5 days
• Severe headache, high persistent fever, or signs of dehydration develop
• Difficulty swallowing, drooling, or respiratory distress occur
• Purulent nasal discharge persists beyond 10 days (suggests bacterial sinusitis)