Does Sore Throat Require Antibiotics?
Most sore throats do not require antibiotics, as up to 80% are viral in origin, and even bacterial cases are usually self-limiting with minimal benefit from antibiotic treatment. 1
Risk Stratification Using Centor Criteria
The decision to test or treat depends on clinical risk assessment using the Centor criteria, which include: fever by history, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 1, 2
Apply the following algorithm based on Centor score:
- 0-1 criteria: Do not test or treat with antibiotics—viral etiology is most likely, provide symptomatic treatment only 1, 2
- 2 criteria: Consider testing with rapid antigen detection test (RADT) or throat culture 2
- 3-4 criteria: Perform RADT or throat culture before prescribing antibiotics 1, 2
The Centor criteria have low positive predictive value, so their primary utility is identifying patients with low probability of Group A Streptococcus who do not warrant testing. 1
When Testing Is Indicated
Do not test patients with clear viral symptoms including cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal lesions (ulcers or vesicles), as testing leads to false-positive results in asymptomatic carriers and unnecessary antibiotic use. 1, 2
RADT is the preferred initial test and does not require confirmatory throat culture after a negative result in adults or children. 1, 2 Throat culture is not necessary for routine diagnosis. 1
Antibiotic Benefits Are Modest at Best
Even when Group A Streptococcus is confirmed, antibiotics provide only modest symptom reduction (approximately 16 hours shorter duration) and should not be prescribed to prevent rheumatic fever or acute glomerulonephritis in low-risk patients without previous rheumatic fever history. 1
Antibiotics do not meaningfully prevent suppurative complications such as peritonsillar abscess, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis. 1
Symptomatic Treatment Is First-Line
Ibuprofen or paracetamol (acetaminophen) are recommended for relief of acute sore throat symptoms regardless of etiology. 1, 3
Corticosteroids in conjunction with antibiotics can be considered in adult patients with more severe presentations (3-4 Centor criteria), but are not routinely recommended. 1
Critical Red Flags Requiring Urgent Evaluation
Immediately evaluate for life-threatening conditions if the patient presents with:
- Difficulty swallowing, drooling, or neck swelling (suggests peritonsillar abscess, parapharyngeal abscess, or epiglottitis) 1, 2
- Severe unilateral throat pain with trismus and uvular deviation (peritonsillar abscess) 2
- Persistent fever with neck pain in adolescents/young adults with severe pharyngitis (consider Lemierre syndrome—suppurative thrombophlebitis of internal jugular vein caused by Fusobacterium necrophorum, implicated in 10-20% of endemic pharyngitis cases) 1, 2, 4
Common Pitfalls to Avoid
Never prescribe antibiotics based on clinical features alone without microbiological confirmation, as clinical features cannot reliably distinguish Group A Streptococcus from viral pharyngitis. 2
The most dangerous error is missing Lemierre syndrome in adolescents and young adults with severe pharyngitis—maintain high suspicion even in the absence of fever, particularly in elderly, immunocompromised, or antibiotic-pretreated patients. 4
If Lemierre syndrome is suspected, notify the laboratory immediately, as F. necrophorum requires special anaerobic culture techniques not routinely used for throat specimens. 4
When Antibiotics Are Prescribed
If testing confirms Group A Streptococcus and antibiotics are deemed necessary (typically only for 3-4 Centor criteria), penicillin remains first-line therapy with clarithromycin as an alternative for penicillin-allergic patients. 5 Treatment duration is 5-7 days for uncomplicated streptococcal pharyngitis. 5
Avoid nonrecommended broad-spectrum antibiotics (extended-spectrum macrolides, fluoroquinolones, cephalosporins) which are frequently overprescribed despite lack of superiority and contribute to antimicrobial resistance. 6