When should a patient with a sore throat, potentially with a history of respiratory or cardiac disease, or being elderly or immunocompromised, be admitted to the hospital?

Hospital Admission Criteria for Sore Throat

Most patients with sore throat do not require hospital admission, but immediate hospitalization is mandatory for those with airway compromise, severe systemic infection, immunocompromise with concerning features, or life-threatening complications such as epiglottitis, retropharyngeal abscess, or cardiac involvement. 1, 2

Red Flags Requiring Immediate Admission

Airway Compromise

• Respiratory distress, stridor, or inability to handle secretions requires emergency hospitalization and potential airway intervention 1
• Laryngeal edema, cherry-red epiglottis (suggesting epiglottitis), or severe pharyngeal swelling mandate immediate admission 3, 1
• Oxygen saturation <92% on room air requires hospitalization 4
• Respiratory rate >30 breaths/min in adults or >50 breaths/min in older children indicates severe disease 4

Severe Systemic Infection or Sepsis

• Hypotension (systolic BP <90 mmHg or diastolic <60 mmHg), tachycardia >125 bpm, or signs of septic shock require immediate admission 4, 5
• Temperature <35°C or >40°C with altered mental status 4
• Evidence of deep space neck infection (retropharyngeal or peritonsillar abscess) requiring surgical drainage 3, 1

High-Risk Patient Populations

Immunocompromised patients with sore throat and fever warrant a lower threshold for admission 4:

• Patients receiving chemotherapy, immunosuppressive therapy, or corticosteroids 4
• Solid organ or hematopoietic stem cell transplant recipients 4
• HIV-positive individuals, particularly with CD4+ counts <200 cells/mm³ 4
• Patients with hematological malignancies or solid tumors 4

Elderly patients (≥65 years) with concerning features should be admitted 4:

• Presence of chronic cardiopulmonary disease (COPD, heart failure) 4
• Diabetes mellitus, chronic renal failure, or chronic liver disease 4
• Inability to maintain oral intake or dehydration 4
• Absence of reliable caregiver at home 4

Life-Threatening Complications

Cardiac involvement from diphtheria or other bacterial toxins requires immediate admission and intensive monitoring 2:

• Presence of characteristic diphtheritic membrane with systemic symptoms 3, 2
• New cardiac symptoms (chest pain, dyspnea, arrhythmias) in context of severe pharyngitis 2
• Severe global systolic dysfunction or heart failure 2

Specific Clinical Scenarios

Suspected Epiglottitis

• Any patient with suspected epiglottitis requires immediate hospitalization with airway management as the priority 1
• Do not delay for imaging or laboratory tests if clinical suspicion is high 1
• Maintain patient in position of comfort and avoid agitation 1

Deep Space Neck Infections

• Peritonsillar or retropharyngeal abscess requires surgical drainage and inpatient management 3, 1
• Swollen neck, difficulty swallowing, and fever progressing over days suggest deep infection 2

Viral Infections in High-Risk Patients

RSV or influenza in elderly or immunocompromised patients may require admission 4:

• Immunocompromised patients with RSV have 90-day mortality rates up to 52.8% 4
• Progression from upper to lower respiratory tract infection occurs in 40-60% of HSCT recipients 4
• Elderly patients (≥75 years) with underlying cardiopulmonary disease and viral pharyngitis progressing to pneumonia 4

Social and Functional Considerations

Admit if the patient cannot be safely managed at home 4:

• Inability to take or tolerate oral medications 5
• Intractable vomiting preventing hydration 5
• No responsible caregiver available for monitoring 4
• Inability to return for follow-up within 24-48 hours 5, 6

Outpatient Management Requirements

Patients managed as outpatients must meet ALL of the following criteria 6:

• No red flags present (immunosuppression, severe comorbidity, airway compromise) 6
• Able to maintain oral intake and hydration 4, 6
• Oxygen saturation ≥92% on room air 4
• Reliable caregiver support and ability to return if worsening 4, 6
• Clinical reassessment planned within 24-48 hours 5, 6

Common Pitfalls to Avoid

• Do not underestimate severity in immunocompromised or elderly patients, even with seemingly mild symptoms 4, 1
• Do not delay airway management while pursuing diagnostic workup in suspected epiglottitis 1
• Do not discharge patients with persistent high fever and systemic symptoms without excluding serious bacterial infection 4, 2
• Do not assume viral etiology in immunocompromised patients without appropriate testing 4