What is the recommended treatment for a patient with a sore throat, considering potential bacterial infections like strep throat and possible allergies or asthma?

Treatment for Sore Throat

For acute sore throat, ibuprofen or paracetamol (acetaminophen) are the recommended first-line treatments for symptom relief, with antibiotics reserved only for patients with confirmed Group A streptococcal infection (typically those with 3-4 Centor criteria and positive rapid antigen test). 1, 2

Symptomatic Treatment (First-Line for All Patients)

Analgesics

• Ibuprofen provides slightly superior pain relief compared to paracetamol, particularly after 2 hours of administration, and should be considered the preferred first-line systemic analgesic 2, 3
• Paracetamol (acetaminophen) is an effective alternative with equivalent safety profile for short-term use 1, 2
• Both medications have low risk of adverse effects when used according to directions 2
• Aspirin and throat lozenges can also help reduce pain 1

Additional Symptomatic Measures

• Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg lozenges) have confirmed efficacy in clinical trials and can be recommended as first-line treatment 4
• Salt water gargles and viscous lidocaine are commonly used but have limited supporting data 1
• Adequate hydration with cool liquids is encouraged 5

What NOT to Use

• Zinc gluconate is not recommended due to conflicting efficacy results and increased adverse effects 1, 2
• Local antibiotics or antiseptics should not be used due to lack of efficacy data 2, 4
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended 1, 2

Risk Stratification Using Centor Criteria

Before considering antibiotics, assess the likelihood of bacterial (Group A streptococcal) pharyngitis using the Centor scoring system 1, 5:

Centor Criteria (1 point each):

• Fever by history
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough 5

Management Based on Score:

• 0-2 points (Low Risk): Viral pharyngitis likely—provide symptomatic treatment only, no antibiotics indicated 1, 2, 6
• 3 points (Moderate Risk): Consider delayed antibiotic prescription strategy or rapid antigen detection test (RADT) 5, 6
• 3-4 points (High Risk): Perform RADT or throat culture; treat with antibiotics only if positive 1, 5

Antibiotic Therapy (Only for Confirmed Streptococcal Infection)

When to Test and Treat

• Test patients with 3-4 Centor criteria using RADT and/or throat culture 1, 5
• Throat culture is not necessary after a negative RADT for diagnosis of Group A streptococci 1
• Prescribe antibiotics only if Group A Streptococcus is confirmed 1, 2

First-Line Antibiotic Regimen

• Penicillin V is the first-choice antibiotic: 250-500 mg twice or three times daily for 10 days 1, 2, 5, 7
• Penicillin is preferred due to cost, narrow spectrum of activity, and effectiveness 8
• Amoxicillin is equally effective and more palatable as an alternative 9, 8

Alternative Regimens (for Penicillin Allergy)

• First-generation cephalosporins 1, 8
• Clindamycin 5
• Azithromycin or clarithromycin 5
• Erythromycin 8

Important Antibiotic Considerations

• Use penicillin with caution in individuals with histories of significant allergies and/or asthma 7
• Even with confirmed streptococcal infection, antibiotics only shorten symptom duration by 1-2 days, with number needed to treat of 6 after 3 days 1
• The modest benefits must be weighed against side effects, impact on microbiota, antibiotic resistance, medicalisation, and costs 1, 2
• Prevention of suppurative complications is not a specific indication for antibiotic therapy in routine sore throat 1
• Most sore throats resolve within 7 days without antibiotics 1, 5

Red Flags Requiring Urgent Evaluation

Immediately evaluate for severe complications if any of the following are present 5:

Peritonsillar Abscess

• Unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," severe difficulty swallowing 5

Retropharyngeal Abscess

• Neck stiffness, neck tenderness or swelling, drooling, difficulty swallowing 5

Epiglottitis (Airway Emergency)

• Drooling, stridor, sitting forward position, respiratory distress 5

Lemierre Syndrome

• Severe pharyngitis with high fever in adolescents and young adults—can progress to life-threatening septic thrombophlebitis 1, 5

These conditions require immediate imaging, specialist consultation, and urgent treatment, not empiric antibiotics based on clinical presentation alone 10, 5

Special Considerations for Persistent Symptoms

• Sore throat lasting beyond 2 weeks is atypical and warrants evaluation for non-infectious causes 5
• Consider laryngoscopy to visualize the larynx and pharynx 5
• Evaluate for gastroesophageal reflux disease, neoplastic processes, or chronic carrier state 5

Corticosteroids (Limited Role)

• Corticosteroids are not routinely recommended for sore throat treatment 2
• Can be considered in adult patients with severe presentations (3-4 Centor criteria) when used in conjunction with antibiotic therapy, using single low-dose oral dexamethasone (maximum 10 mg) 2
• Should not be used in patients with 0-2 Centor criteria 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically without clinical assessment—over 60% of adults with sore throat receive unnecessary antibiotics 5
• Do not treat every organism isolated from a throat culture (e.g., E. coli represents colonization, not infection) 10
• Do not use broad-spectrum antibiotics without confirming a bacterial pathogen 10
• Antibiotics should not be used in patients with 0-2 Centor criteria to relieve symptoms 2
• Reassure patients that typical sore throat duration is less than 1 week and antibiotics usually do little to alleviate symptoms 1