What is the best approach to manage a sore throat in a 23-year-old male?

Management of Sore Throat in a 23-Year-Old Male

Start with ibuprofen or paracetamol for symptomatic relief, and reserve antibiotics only for patients with 3-4 Centor criteria after weighing modest benefits against risks of resistance and side effects. 1, 2

Initial Assessment Using Centor Criteria

Evaluate the patient using the Centor scoring system to stratify risk of group A streptococcal infection 1:

• Fever (temperature >38°C)
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough

Each criterion = 1 point (maximum 4 points) 1

First-Line Symptomatic Treatment

Ibuprofen is the preferred first-line analgesic, showing slightly better efficacy than paracetamol particularly at 2 hours post-administration 2, 3:

• Both medications are equally safe for short-term use 2
• Either option provides effective pain relief with low risk of adverse effects 1
• Ibuprofen demonstrates the best benefit-risk profile among systemic analgesics 4

Antibiotic Decision Algorithm

For Centor Score 0-2 (Low Risk):

Do NOT prescribe antibiotics 1, 2:

• Antibiotics provide no meaningful symptom relief in this population 1
• No need for rapid antigen testing (RAT) or throat culture 1
• Continue symptomatic treatment with ibuprofen or paracetamol 1

For Centor Score 3-4 (High Risk):

Consider antibiotics after shared decision-making with the patient 1, 2:

• Discuss that antibiotics provide only modest symptom reduction 1
• Weigh benefits against side effects, impact on gut microbiota, antibiotic resistance, and costs 1
• Optional: Use rapid antigen test to confirm group A streptococcus, though throat culture is not necessary after negative RAT 1

If antibiotics are indicated: Penicillin V is first-line 1, 2:

• Dose: 250 mg twice or three times daily for 10 days 1
• No evidence supports shorter treatment duration 1

Additional Treatment Considerations

Corticosteroids:

Can be considered only in severe presentations (3-4 Centor criteria) when used with antibiotics 1, 2:

• Not routinely recommended 1
• Use single low-dose oral dexamethasone (maximum 10 mg) if prescribed 2

Adjunctive Topical Therapy:

Local anesthetic sprays or lozenges may provide additional symptom relief 3, though systemic analgesics remain the primary treatment 2

What NOT to Use

Avoid these interventions as they lack efficacy or have unfavorable risk-benefit profiles:

• Zinc gluconate - not recommended due to conflicting results and increased adverse effects 1, 2, 3
• Local antibiotics or antiseptics - ineffective given viral etiology of most cases 2, 3, 4
• Herbal treatments or acupuncture - inconsistent evidence 1, 2, 3
• Routine biomarkers (CRP, procalcitonin) - not necessary for assessment 1

Critical Pitfalls to Avoid

Do not prescribe antibiotics to prevent complications in low-risk patients 1:

• Antibiotics do not prevent rheumatic fever or acute glomerulonephritis in patients without prior rheumatic fever history 1
• Prevention of suppurative complications (quinsy, otitis media, sinusitis, mastoiditis) is not an indication for antibiotics 1

Remember that most sore throats are viral 1, 5:

• Less than 35% are bacterial 6
• Mean duration is 7 days regardless of treatment 6
• Asymptomatic carriage of group A streptococcus is common (2.3% in adults aged 15-44 years) 1

Clinical Reasoning

The evidence strongly supports a conservative approach prioritizing symptomatic relief over antibiotics. Even in high-risk patients (3-4 Centor criteria), antibiotics only modestly shorten symptom duration 1, 6. The guideline recommendations from the European Society of Clinical Microbiology and Infectious Diseases 1 provide the highest quality evidence (A-1 level) and are reinforced by recent summaries 2, 3. This approach reduces unnecessary antibiotic exposure, preserves the microbiome, and combats resistance while maintaining patient safety and quality of life.