How to manage an adult patient with a right-sided sore throat and no underlying medical conditions?

Management of Right-Sided Sore Throat in Adults

Use the Modified Centor criteria to risk-stratify this patient, test for Group A Streptococcus only if the score is ≥3, and treat with antibiotics only if testing confirms streptococcal infection—otherwise provide symptomatic treatment with NSAIDs or acetaminophen. 1

Initial Assessment: Apply Modified Centor Criteria

Calculate the patient's score based on these four criteria 1, 2:

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

Risk Stratification Based on Score:

• 0-2 points: Viral pharyngitis is most likely (65-85% of cases are viral). Do NOT test for streptococcus and do NOT prescribe antibiotics 1, 2

• 3 points: Moderate risk—consider rapid antigen detection test (RADT) or throat culture 1, 2

• 4 points: High risk—perform RADT and/or throat culture; may consider empiric treatment while awaiting results 2

Critical Red Flags Requiring Immediate Evaluation

The unilateral nature of this patient's symptoms warrants heightened vigilance. Immediately evaluate for these life-threatening conditions if present 1:

• Difficulty swallowing, drooling, neck tenderness, or swelling: Suspect peritonsillar abscess, parapharyngeal abscess, or epiglottitis 1

• Unilateral tonsillar swelling with uvular deviation: Peritonsillar abscess (quinsy) 3

• Severe pharyngitis with persistent high fever in adolescents/young adults: Consider Lemierre syndrome—a rare but life-threatening condition requiring urgent diagnosis and treatment 1, 3

Testing Strategy

Only test patients meeting ≥3 Centor criteria 1, 2:

• Rapid antigen detection test (RADT) is the first-line diagnostic tool 1

• Throat culture should follow negative RADT in children/adolescents, but is optional in adults 2, 4

• Do NOT test patients with viral features: cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal ulcers/vesicles 1, 3

Treatment Algorithm

If Testing Confirms Group A Streptococcus:

First-line antibiotic: Penicillin V 250 mg PO twice or three times daily for 10 days 3, 5, 4

Alternative: Amoxicillin 500 mg PO three times daily for 10 days 5, 4

For penicillin allergy (non-anaphylactic): First-generation cephalosporin 4

Important context: Antibiotics shorten symptom duration by only 1-2 days (number needed to treat = 6 at 3 days, 21 at 1 week), but may prevent complications including peritonsillar abscess and acute rheumatic fever 1, 2

If Viral Pharyngitis (Score <3 or Negative Testing):

Symptomatic treatment is the cornerstone of management 1, 3, 2:

• Ibuprofen or acetaminophen for pain relief 1, 3
• Throat lozenges 1
• Salt water gargles (though limited evidence) 1, 2

Reassure the patient: Typical viral sore throat resolves in less than 7 days, with improvement expected after 3-4 days 3, 2

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics without confirmed streptococcal infection—over 60% of adults with sore throat receive unnecessary antibiotics, contributing to resistance and adverse effects without benefit 1, 3

• Do NOT ignore unilateral presentation—while most sore throats are benign and bilateral, unilateral symptoms increase suspicion for peritonsillar abscess or other suppurative complications 3, 6

• Do NOT test patients with <3 Centor criteria—this wastes resources and leads to false positives driving unnecessary antibiotic use 1, 2

• Do NOT use azithromycin or clarithromycin as first-line therapy—significant resistance exists in many U.S. regions 4

Follow-Up Considerations

Re-evaluate if 7, 4:

• Symptoms worsen after 48-72 hours of appropriate antibiotic therapy
• Symptoms persist beyond 5 days after starting antibiotics
• Symptoms last beyond 3 weeks (requires laryngoscopy to exclude serious pathology including malignancy) 7