What is the diagnosis and management for a patient with a 7-day history of cold and sore throat?

Management of 7-Day Cold and Sore Throat

This is almost certainly a viral upper respiratory infection that does not require antibiotics, and treatment should focus on symptom relief with ibuprofen or paracetamol. 1, 2, 3

Diagnosis

Most Likely Etiology

• The vast majority (65-85%) of acute sore throat cases are viral in origin, caused by rhinovirus, coronavirus, adenovirus, influenza, or other respiratory viruses. 2
• Bacterial causes (primarily Group A streptococcus) account for only 5-15% in adults. 2
• At 7 days duration with "cold" symptoms, this presentation strongly suggests viral pharyngitis rather than bacterial infection. 1, 2

Clinical Features Suggesting Viral (Not Bacterial) Infection

The presence of "cold" symptoms is the key diagnostic clue here:

• Cough, runny nose (coryza), hoarseness, or conjunctivitis strongly indicate viral pharyngitis. 2
• Viral infections typically present with gradual onset and multiple upper respiratory symptoms. 2, 4

When to Consider Bacterial Pharyngitis

You would need to assess for Group A streptococcus if the patient has:

• Sudden-onset sore throat, fever, tonsillar exudates, tender anterior cervical lymph nodes, and absence of cough (Centor criteria). 1, 2, 5
• With "cold" symptoms present, bacterial pharyngitis is highly unlikely. 2

Management

Symptomatic Treatment (First-Line)

Either ibuprofen or paracetamol (acetaminophen) are strongly recommended for pain relief, as these are the most effective treatments available:

• Ibuprofen provides slightly more effective pain relief than paracetamol. 1, 2, 3, 5
• These medications address both throat pain and any associated fever. 3, 5

What NOT to Use

• Zinc gluconate is not recommended for sore throat treatment. 1, 2
• Herbal treatments and acupuncture have inconsistent evidence and cannot be reliably recommended. 1, 2, 5

Antibiotics: NOT Indicated

Antibiotics should NOT be prescribed for this patient for several critical reasons:

• Most sore throats are viral and self-limiting, resolving within 7 days without antibiotics. 1, 2, 3
• The presence of "cold" symptoms makes bacterial infection highly unlikely. 2
• Antibiotics provide no benefit for viral pharyngitis and contribute to antibiotic resistance, side effects, and unnecessary costs. 1, 2, 3
• Even if bacterial pharyngitis were present, antibiotics are not needed to prevent complications like rheumatic fever in low-risk patients (those without previous rheumatic fever). 2, 5

If You Still Suspect Bacterial Infection

Only consider testing and antibiotics if the patient has:

• High Centor score (3-4 points): fever, tonsillar exudates, tender anterior cervical nodes, NO cough. 1, 5
• In such cases, confirm with rapid antigen test or throat culture before prescribing antibiotics. 1, 2
• If antibiotics are indicated after positive testing, penicillin V 250-500 mg twice or three times daily for 10 days is first-line therapy. 1, 2, 5

When to Reassess

Red Flags Requiring Immediate Evaluation

Refer urgently if the patient develops:

• Severe difficulty swallowing or breathing, drooling, stridor, or respiratory distress (suggests epiglottitis—an airway emergency). 5, 6
• Unilateral tonsillar swelling, uvular deviation, trismus, or "hot potato voice" (suggests peritonsillar abscess). 5
• Neck stiffness, severe neck tenderness or swelling (suggests retropharyngeal abscess). 5

Persistent Symptoms Beyond 2 Weeks

• A sore throat lasting beyond 2 weeks is atypical and warrants evaluation for non-infectious causes such as gastroesophageal reflux disease or neoplastic processes. 5
• Consider laryngoscopy to directly visualize the pharynx and larynx. 5

Patient Education

Inform the patient that:

• Viral sore throat typically resolves within 7 days without antibiotics. 2, 3
• Symptom relief with ibuprofen or paracetamol is the appropriate treatment. 2, 3, 5
• Antibiotics will not help viral infections and can cause side effects. 2, 3