What is the recommended treatment for an adult or child with no significant medical history presenting with a sore throat, potentially caused by streptococcal pharyngitis or other bacterial infections?

Treatment for Sore Throat

For adults and children with sore throat, test patients with 3-4 Centor criteria using rapid antigen detection test (RADT) and treat only confirmed Group A Streptococcus (GAS) with penicillin or amoxicillin for 10 days, while providing symptomatic relief with NSAIDs or acetaminophen for all patients. 1

Initial Risk Stratification Using Clinical Criteria

Apply the modified Centor criteria to determine likelihood of bacterial pharyngitis before testing 1:

• Fever by history (1 point)
• Tonsillar exudates (1 point)
• Tender anterior cervical adenopathy (1 point)
• Absence of cough (1 point)

Patients with 0-2 Centor criteria: Do not test and do not treat with antibiotics 1. These patients have low probability of GAS and antibiotics provide no meaningful benefit.

Patients with 3-4 Centor criteria: Proceed with RADT testing 1, 2. These patients have sufficient pretest probability to warrant diagnostic confirmation.

Diagnostic Testing Approach

Perform RADT in patients meeting 3-4 Centor criteria 1:

• If RADT is positive in adults: Treat with antibiotics, no backup culture needed 1
• If RADT is negative in adults: No backup culture needed under usual circumstances 1
• If RADT is negative in children/adolescents: Obtain backup throat culture due to higher disease prevalence and rheumatic fever risk 1

Do not test children under 3 years old unless specific risk factors exist (e.g., older sibling with confirmed GAS), as acute rheumatic fever is rare in this age group 1.

Red Flags Requiring Urgent Evaluation

Immediately evaluate for life-threatening complications if any of these features are present 1, 3:

• Peritonsillar abscess: Unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," severe difficulty swallowing
• Retropharyngeal abscess: Neck stiffness, neck tenderness or swelling, drooling
• Epiglottitis: Drooling, stridor, sitting forward position, respiratory distress (airway emergency)
• Lemierre syndrome: Severe pharyngitis with persistent high fever in adolescents/young adults

Antibiotic Treatment for Confirmed GAS

First-line therapy 1, 3:

• Penicillin V: 250-500 mg orally twice or three times daily for 10 days
• Amoxicillin: 500 mg orally twice daily for 10 days (often preferred in young children due to taste and suspension availability) 1, 4

For penicillin-allergic patients (non-anaphylactic) 1, 3, 5:

• First-generation cephalosporins for 10 days

For penicillin-allergic patients (anaphylactic) 1, 3:

• Clindamycin
• Azithromycin (note: significant resistance exists in some U.S. regions) 6, 5
• Clarithromycin

The 10-day duration is critical for adequate eradication of GAS from the pharynx 1.

Symptomatic Management for All Patients

Regardless of etiology, provide analgesic therapy 1, 3:

• NSAIDs (ibuprofen): More effective than acetaminophen for pain and fever relief 3, 2
• Acetaminophen: Alternative option
• Throat lozenges: Can provide additional relief 1

Corticosteroids are not recommended for routine use, as they provide only minimal symptom reduction 2.

Understanding the Modest Benefits of Antibiotics

Even with confirmed GAS, antibiotics provide limited symptomatic benefit 1:

• Shorten duration of sore throat by only 1-2 days 1
• Number needed to treat is 6 at day 3 and 21 at week 1 to reduce symptoms 1
• Primary value is preventing complications (acute rheumatic fever, peritonsillar abscess) and reducing transmission 1

In modern Western settings, the absolute risk of rheumatic fever and acute glomerulonephritis is extremely low, making prevention of these complications less relevant for low-risk patients 1.

Delayed Prescribing Strategy

For patients with 3 Centor criteria (moderate risk), consider delayed antibiotic prescribing 1:

• Provide prescription but instruct patient to fill only if symptoms worsen or persist beyond 48 hours
• This approach reduces antibiotic use without increasing complication rates 1

Common Pitfalls to Avoid

Do not prescribe antibiotics empirically without testing 1, 3. Over 60% of adults with sore throat receive unnecessary antibiotics, contributing to resistance.

Do not apply Centor criteria to children under 3 years or to patients with clear viral features (cough, rhinorrhea, hoarseness, oral ulcers) 1.

Do not assume all sore throats lasting beyond 1 week are simple infections 7, 8. Most viral and bacterial pharyngitis resolves within 7 days; persistence beyond 2 weeks warrants evaluation for non-infectious causes including gastroesophageal reflux disease or neoplastic processes.

Do not treat chronic GAS carriers with antibiotics 1. They are unlikely to spread infection and are at minimal risk for complications.

When to Reevaluate

Reassess patients if 5:

• Symptoms worsen after appropriate antibiotic initiation
• Symptoms persist 5 days after starting treatment
• Sore throat persists beyond 2 weeks (consider non-infectious etiologies) 7, 3