When is a patient with a sore throat and potential underlying medical conditions, such as immunocompromised states or heart conditions, admissible for further evaluation and treatment?

Hospital Admission Criteria for Sore Throat

A patient with sore throat requires hospital admission when they present with severe difficulty swallowing or breathing, signs of airway compromise, suspected peritonsillar abscess, or features suggesting Lemierre syndrome—particularly adolescents and young adults with persistent fever, neck pain/swelling, and sepsis following pharyngitis. 1, 2

Immediate Admission Indications

Airway Compromise

• Severe difficulty swallowing or breathing mandates immediate evaluation and likely admission 1
• Drooling, stridor, or inability to handle secretions indicate potential airway obstruction requiring urgent intervention 1

Suppurative Complications

Peritonsillar Abscess (Quinsy)

• Young adults presenting with severe unilateral throat pain, trismus, "hot potato voice," and uvular deviation require admission for drainage and IV antibiotics 1
• This polymicrobial infection requires prompt medical attention to prevent further complications 1

Lemierre Syndrome

• Adolescents and young adults with severe pharyngitis who develop persistent fever, neck pain/swelling, and signs of sepsis require immediate admission 2
• This life-threatening condition has a 6.4% mortality rate even with treatment and involves septic thrombophlebitis of the internal jugular vein 2
• Clinicians must maintain high suspicion in this age group, as the incidence has increased over the past decade due to decreased antibiotic prescribing for upper respiratory infections 2
• Critical pitfall: Do not dismiss Lemierre syndrome based solely on absence of fever—elderly, immunocompromised, or antibiotic-pretreated patients may not mount a febrile response 2

High-Risk Patient Populations Requiring Lower Threshold for Admission

According to UK NHS Clinical Knowledge Summaries and NICE guidelines, the following patients are at increased risk of complications and warrant consideration for admission with more severe presentations 3:

• Immunocompromised patients (increased risk of severe infections and atypical presentations) 3
• History of valvular heart disease (risk of endocarditis from bacteremia) 3
• History of rheumatic fever (at risk for recurrence with untreated streptococcal infection) 3
• Male patients aged 21-40 years who smoke (significantly higher risk of peritonsillar abscess) 3

Clinical Assessment for Admission Decision

Red Flag Symptoms Requiring Urgent Evaluation

• Severe neck swelling or tenderness suggesting deep space infection 2
• Respiratory distress or stridor 1
• Inability to swallow saliva or maintain hydration 1
• Signs of sepsis (hypotension, tachycardia, altered mental status) 2
• Persistent high fever despite appropriate outpatient management 2

Severe Presentation Criteria (Consider Admission)

Patients with 3-4 Centor criteria (sudden-onset sore throat, fever, tonsillar exudates, tender anterior cervical adenopathy, absence of cough) who also have 3, 4:

• Marked tonsillar swelling causing airway narrowing
• Severe odynophagia preventing oral intake
• Dehydration requiring IV fluids
• Inability to tolerate oral antibiotics

Special Considerations

Lemierre Syndrome Diagnostic Pitfall

• Notify the laboratory immediately if Lemierre syndrome is suspected, as Fusobacterium necrophorum requires special anaerobic culture techniques not routinely used for throat specimens 2
• Antibiotic therapy should not be delayed while awaiting culture results when clinical suspicion is high 2
• Standard pharyngitis treatment duration is inadequate—Lemierre syndrome requires prolonged therapy beyond typical 10-day courses 2

Outpatient Management Appropriate For

• Uncomplicated viral pharyngitis (65-85% of cases) 1, 4
• Confirmed streptococcal pharyngitis in otherwise healthy patients who can tolerate oral antibiotics and maintain hydration 3, 4
• Patients with 0-2 Centor criteria without high-risk features 3