What is the appropriate treatment for a patient presenting with a sore throat and fever, potentially indicating a bacterial infection?

Management of Sore Throat and Fever

Initial Assessment: Use Clinical Scoring to Guide Testing

Most patients with sore throat and fever do not need antibiotics, and you should use the Centor criteria to determine who requires testing for Group A Streptococcus before considering any antibiotic therapy. 1

Apply the Modified Centor Criteria (1 point each):

• Fever by history 1
• Tonsillar exudates 1
• Tender anterior cervical adenopathy 1
• Absence of cough 1

Risk-Stratified Approach Based on Score:

0-2 Centor criteria (Low Risk):

• Do NOT perform rapid antigen detection testing (RADT) or throat culture 1
• Do NOT prescribe antibiotics 1
• Provide symptomatic treatment only 1, 2

3-4 Centor criteria (High Risk):

• Perform RADT or throat culture to confirm Group A Streptococcus 1
• Only prescribe antibiotics if testing confirms streptococcal infection 1
• Even with positive testing, discuss with patients that antibiotics provide only modest symptom reduction (shortening illness by approximately 16 hours) and must be weighed against side effects 1

Red Flags Requiring Urgent Evaluation

If the patient has any of these severe symptoms, immediately evaluate for life-threatening complications rather than treating as simple pharyngitis: 1, 3

• Difficulty swallowing or drooling 1, 3
• Neck tenderness or swelling 1, 3
• Trismus (inability to open mouth) 3
• Unilateral tonsillar swelling with uvular deviation 3
• "Hot potato voice" 3
• Stridor or respiratory distress 3

These symptoms suggest peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome, which require imaging and specialist consultation, not empiric antibiotics 1, 3

Symptomatic Treatment (First-Line for All Patients)

Prescribe either ibuprofen or acetaminophen (paracetamol) for pain relief—this is strongly recommended and should be offered to all patients regardless of whether antibiotics are indicated. 1, 3

• These analgesics are the most effective symptomatic treatments for acute sore throat 1
• Encourage adequate hydration with cool liquids 2
• Most viral sore throats resolve within 7 days without antibiotics 2

Antibiotic Therapy (Only When Indicated)

If Group A Streptococcus is confirmed by testing in a patient with 3-4 Centor criteria, prescribe penicillin V twice or three times daily for 10 days. 1

Key Points About Antibiotic Use:

• Penicillin V is first-line therapy 1
• Treatment duration should be 10 days (insufficient evidence for shorter courses) 1
• Clarithromycin is an alternative for penicillin-allergic patients 2
• Antibiotics should NOT be used to prevent rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous rheumatic fever history) 1
• Antibiotics do NOT meaningfully prevent suppurative complications like peritonsillar abscess, acute otitis media, or sinusitis 1

Common Pitfalls to Avoid

Do not prescribe antibiotics based on clinical impression alone without confirming streptococcal infection with testing. 1 The Centor criteria have low positive predictive value and are used to identify who needs testing, not who needs treatment 1

Do not routinely use biomarkers like C-reactive protein or procalcitonin in the assessment of acute sore throat—they are not necessary 1

Do not routinely prescribe corticosteroids in conjunction with antibiotics, though they can be considered in adults with severe presentations (3-4 Centor criteria) 1

Do not treat organisms like E. coli if isolated from throat culture—these represent colonization, not infection, and should not be treated with antibiotics 4

When to Reassess

If symptoms persist beyond 7 days or worsen despite appropriate management, reassess for complications or alternative diagnoses. 2 Consider Lemierre syndrome in adolescents and young adults with severe, persistent pharyngitis, as this is a rare but life-threatening condition caused by Fusobacterium necrophorum 1, 3, 5