What is the best initial treatment approach for an otherwise healthy adult or child with a sore throat, considering potential streptococcal infection or viral cause?

Best Treatment for Sore Throat

For most adults and children with sore throat, symptomatic treatment with ibuprofen or acetaminophen is the appropriate initial approach, reserving antibiotics only for patients with 3-4 Centor criteria AND confirmed Group A Streptococcus infection by rapid antigen test or culture. 1, 2

Initial Assessment Using Centor Criteria

Apply the Centor scoring system to every patient presenting with sore throat 1:

• Fever by history = 1 point 3
• Tonsillar exudates = 1 point 3
• Tender anterior cervical adenopathy = 1 point 1
• Absence of cough = 1 point 3

For Patients with 0-2 Centor Criteria (Low Risk)

• Do not perform testing and do not prescribe antibiotics 1, 3
• The vast majority (65-85%) of these cases are viral and self-limiting 2
• Provide symptomatic treatment only 1, 2

For Patients with 3-4 Centor Criteria (Higher Risk)

• Perform rapid antigen detection test (RADT) immediately 1, 3
• If RADT is positive: treat with antibiotics (no culture needed) 3
• If RADT is negative: confirm with throat culture before treating 3
• Only prescribe antibiotics if Group A Streptococcus is confirmed 1, 2

Symptomatic Treatment (For All Patients)

Ibuprofen or acetaminophen (paracetamol) are the most effective treatments for pain relief and should be offered to all patients regardless of etiology 1, 2:

• These analgesics provide significant symptom relief 2
• Throat lozenges may provide additional benefit 1
• Encourage adequate hydration with cool liquids 4
• Salt water gargles and viscous lidocaine have limited evidence but are commonly used 1

Antibiotic Treatment (Only When Indicated)

When Group A Streptococcus is confirmed in patients with 3-4 Centor criteria:

First-Line Treatment

Penicillin V is the treatment of choice 1, 5:

• Dosage: 500 mg orally twice daily OR 250 mg three times daily for 10 days 3, 5
• Penicillin remains first-line due to proven efficacy, safety, narrow spectrum, low cost, and zero resistance development over five decades 1
• The 10-day duration is necessary to eradicate the organism and prevent complications 1, 5

Alternative for Young Children

• Amoxicillin may be used in younger children due to better taste and availability as suspension 1, 6
• Avoid amoxicillin in older children and adolescents due to risk of severe rash if Epstein-Barr virus infection is present 1

For Penicillin Allergy

• Erythromycin or other macrolides are recommended 3

Expected Clinical Course and Patient Education

Most sore throats resolve within 7 days without antibiotics 2, 7:

• Even with confirmed bacterial infection, 82% of untreated patients are symptom-free by one week 8
• Antibiotics shorten symptom duration by only 1-2 days 1, 8
• The number needed to treat to prevent one sore throat at day 3 is less than 6; at week 1 it is 18 8

Educate patients that:

• Viral pharyngitis does not benefit from antibiotics 2, 7
• Antibiotics do not prevent complications in low-risk patients 2, 3
• Symptomatic treatment is highly effective 2

Red Flags Requiring Urgent Evaluation

Immediately evaluate for life-threatening complications if the patient presents with 1, 4:

• Severe difficulty swallowing or breathing 2
• Drooling 1
• Neck tenderness or swelling 1
• Trismus (inability to open mouth) 4
• "Hot potato voice" 4

These symptoms suggest peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome, which require imaging and specialist consultation—not empiric antibiotics 4

Common Pitfalls to Avoid

Do not prescribe antibiotics based on clinical impression alone 1, 9:

• Clinicians overestimate bacterial pharyngitis probability by 80-95% 9
• Up to 70% of sore throat patients receive unnecessary antibiotics nationally 2

Do not treat organisms isolated from throat culture that are not recognized pathogens 4:

• E. coli, if isolated, represents colonization and should not be treated 4
• Only Group A Streptococcus warrants antibiotic treatment in routine pharyngitis 4, 2

Do not use antibiotics to prevent complications in low-risk patients 2, 3:

• Acute rheumatic fever is extremely rare in developed countries 3
• Suppurative complications (otitis media, sinusitis) occur rarely and do not justify routine antibiotic use 3

Weigh modest benefits against harms 1:

• Side effects, disruption of microbiota, antimicrobial resistance, medicalization, and costs must be considered 1
• The modest 1-2 day symptom reduction may not justify antibiotic use in many cases 1, 8