What is the best course of treatment for an otherwise healthy adult patient with a sore throat lasting 7 days?

Evaluation and Management of 7-Day Sore Throat

A sore throat persisting for 7 days requires evaluation for serious complications and non-infectious causes, as most viral and bacterial pharyngitis resolves within this timeframe—symptomatic treatment with ibuprofen or paracetamol should be provided while investigating the underlying cause. 1

Immediate Assessment for Red Flags

First, evaluate for serious complications requiring urgent intervention:

• Peritonsillar abscess: Look for unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," and severe difficulty swallowing 2
• Retropharyngeal abscess: Assess for neck stiffness, neck tenderness or swelling, drooling, and difficulty swallowing 2
• Lemierre syndrome: Consider in young adults with severe pharyngitis and high fever, which can progress to life-threatening septic thrombophlebitis 1, 2
• Epiglottitis: Evaluate for drooling, stridor, sitting forward position, and respiratory distress—this is an airway emergency 2

Why 7 Days Matters

• Most pharyngitis resolves by 7 days: Over 80% of both viral and bacterial cases achieve complete symptom resolution within one week 1
• Even untreated streptococcal pharyngitis typically shows fever and constitutional symptoms disappearing within 3-4 days, with throat soreness lasting at most 1-2 days longer than antibiotic-treated cases 1
• Persistence at 7 days is atypical and warrants consideration beyond simple acute pharyngitis 1

Diagnostic Approach

Consider Non-Infectious Causes

At 7 days duration, broaden your differential:

• Gastroesophageal reflux disease: Can present as chronic throat irritation 1
• Neoplastic processes: Should be considered, particularly in adults with isolated persistent symptoms 1
• Chronic carrier state: Patient may be a streptococcal carrier with concurrent viral pharyngitis 2

Testing Strategy (If Considering Bacterial Cause)

• Obtain throat culture or rapid antigen detection test (RADT) for Group A Streptococcus, even though the prolonged duration makes this diagnosis less likely 1
• If RADT is positive, it confirms streptococcal pharyngitis 1
• If RADT is negative, throat culture backup is generally not necessary in adults due to low incidence and low risk of rheumatic fever 1

Symptomatic Management

Provide analgesics regardless of etiology:

• Ibuprofen or paracetamol are first-line for pain relief 3, 1, 2
• These remain appropriate symptomatic treatment while investigating the underlying cause 1

Antibiotic Treatment (Only If Streptococcal Infection Confirmed)

If testing confirms Group A Streptococcus:

• Penicillin V 250-500 mg twice or three times daily for 10 days is first-line treatment 3, 1, 2, 4
• Alternative options include amoxicillin, first-generation cephalosporin, clindamycin, azithromycin, or clarithromycin 1, 2

However, at 7 days duration, antibiotic benefit for symptom reduction is negligible as the natural course has already exceeded the 1-2 day benefit window that antibiotics provide 1

Common Pitfalls to Avoid

• Do not assume this is simple streptococcal pharyngitis and prescribe antibiotics empirically—the 7-day duration makes this diagnosis unlikely 1
• Do not apply Centor or FeverPAIN scores to this case, as these tools are validated only for acute presentations and not for symptoms persisting 7 days 1
• Do not dismiss the patient with reassurance alone—absence of other symptoms does not rule out serious pathology in a 7-day presentation 1
• Do not use broad-spectrum antibiotics like amoxicillin-clavulanate as first-line therapy, as this increases antibiotic resistance without providing additional clinical benefit 5

When to Consider Further Evaluation

If symptoms persist beyond 14 days:

• The European Society of Clinical Microbiology and Infectious Diseases guideline specifically excludes cases with symptoms >14 days from standard acute pharyngitis algorithms 1
• Laryngoscopy should be considered to directly visualize the larynx and pharynx, typically using transnasal flexible fiberoptic scope 2
• Persistence beyond 2 weeks without other symptoms is atypical and warrants thorough evaluation for non-infectious causes 1