What is the treatment for a sore throat?

Treatment of Sore Throat

For most patients with sore throat, start with ibuprofen or paracetamol (acetaminophen) for symptomatic relief, and reserve antibiotics only for those with high likelihood of bacterial infection (3-4 Centor criteria) after discussing the modest benefits versus risks. 1

First-Line Symptomatic Treatment

Ibuprofen and paracetamol are the recommended first-line treatments for acute sore throat pain relief. 1

• Ibuprofen appears slightly more effective than paracetamol, particularly after 2 hours of administration, and shows the best benefit-risk profile among systemic analgesics 2, 3, 4
• Both medications are safe when used according to directions for short-term treatment, with low risk of adverse effects 1, 5, 2
• For patients with renal impairment, paracetamol is the safer choice due to potential NSAID risks 6

Additional Symptomatic Options

• Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg) can be used as lozenges, throat sprays, or gargles for additional relief 5, 4
• Among local anesthetics, ambroxol has the best documented benefit-risk profile 4

Clinical Assessment Algorithm

Use the Centor scoring system to guide antibiotic decision-making: 1, 6

The Centor criteria include:

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

Score interpretation and management:

Patients with 0-2 Centor Criteria (Low Risk)

• Do NOT use antibiotics - they provide no meaningful symptom relief in this group 1
• Treat with ibuprofen or paracetamol only 1
• Rapid antigen testing (RAT) is not routinely needed 1

Patients with 3-4 Centor Criteria (High Risk)

• Consider rapid antigen testing to confirm group A streptococcal infection 1
• If RAT is performed, throat culture is NOT necessary after a negative RAT 1
• Discuss antibiotic benefits versus risks with the patient - benefits are modest and must be weighed against side effects, antimicrobial resistance, effects on microbiota, medicalization, and costs 1
• If antibiotics are indicated, use penicillin V twice or three times daily for 10 days 1, 6
• Corticosteroids can be considered in conjunction with antibiotic therapy for severe presentations in adults, though not routinely recommended 1, 2

What NOT to Use

Avoid these treatments due to lack of efficacy or unfavorable risk-benefit profiles:

• Local antibiotics or antiseptics - not recommended due to mainly viral origin of most sore throats and lack of efficacy data 5, 2, 4
• Zinc gluconate - not recommended due to conflicting efficacy results and increased adverse effects 1, 5, 2, 6
• Herbal treatments and acupuncture - inconsistent evidence and lack of reliable data supporting efficacy 1, 5, 2, 6

Critical Pitfalls to Avoid

Antibiotics do NOT prevent complications in most patients: 1, 6

• Rheumatic fever and glomerulonephritis prevention - antibiotics should NOT be used for this purpose in low-risk patients (those without previous rheumatic fever history) 1, 6
• Suppurative complications (quinsy, acute otitis media, sinusitis, mastoiditis, cervical lymphadenitis) - prevention is NOT a specific indication for antibiotic therapy; the number needed to treat is 27 or higher to prevent one case of quinsy 1, 6
• Even when antibiotics show benefit, the effect is modest - reducing symptoms on day 3 but with only the group A streptococcus-positive subgroup showing benefit at 1 week 1

Special Considerations

• Biomarkers (C-reactive protein, procalcitonin) are not necessary for routine assessment of acute sore throat 1
• Throat culture is not necessary for routine diagnosis to detect group A streptococci 1
• Clinical scoring systems and rapid tests can be helpful in targeting antibiotic use and reducing unnecessary prescriptions 1