What is the appropriate management for a patient with severe sore throat suspected to be of bacterial origin, considering factors such as age, medical history, and potential allergies?

Management of Severe Sore Throat

In patients with severe sore throat, antibiotics should only be prescribed after confirming Group A streptococcal infection in those with 3-4 Centor criteria, using penicillin V (250 mg twice or three times daily for 10 days) as first-line therapy—but first, you must urgently rule out life-threatening complications like peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome if symptoms are unusually severe or refractory. 1, 2

Step 1: Assess for Life-Threatening Complications

Severe or refractory sore throat requires immediate evaluation for dangerous conditions before considering routine antibiotic therapy. 2

Urgent red flags requiring immediate imaging and specialist consultation include: 2

• Peritonsillar abscess: unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," difficulty swallowing
• Retropharyngeal abscess: neck stiffness, neck tenderness or swelling, drooling, difficulty swallowing
• Epiglottitis: drooling, stridor, sitting forward position, respiratory distress (airway management is paramount)
• Lemierre syndrome: severe pharyngitis in adolescents/young adults progressing to septic thrombophlebitis

These conditions require urgent intervention, not empiric antibiotics based on clinical scoring alone. 2

Step 2: Apply Centor Criteria to Stratify Risk

For patients without red flags, use the Centor scoring system to determine the likelihood of Group A streptococcal infection: 1

The Centor criteria include (1 point each): 1, 3

• Fever by history
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough

Risk stratification by score: 1

• 0-2 points: Low probability of bacterial infection—antibiotics are NOT indicated and should not be prescribed 1
• 3-4 points: Higher probability—consider rapid antigen detection test (RADT) or throat culture before prescribing antibiotics 1

Step 3: Confirm Bacterial Infection Before Prescribing Antibiotics

In patients with 3-4 Centor criteria, perform rapid antigen testing to confirm Group A streptococcus before prescribing antibiotics. 1, 4

• If RADT is performed, throat culture is not necessary after a negative result for diagnosis of Group A streptococci 1
• In children and adolescents, throat culture is recommended after a negative RADT 4
• Do not prescribe antibiotics empirically without microbiological confirmation 1

Common pitfall: Most sore throats (65-85%) are viral, yet 60% or more patients receive antibiotics unnecessarily. 3, 4

Step 4: Antibiotic Selection When Indicated

If Group A streptococcal infection is confirmed in a patient with 3-4 Centor criteria, penicillin V is the first-line antibiotic. 1

Dosing regimen: 1

• Penicillin V: 250 mg twice or three times daily for 10 days
• There is insufficient evidence to support shorter treatment duration 1

For penicillin-allergic patients (non-anaphylactic): 4

• First-generation cephalosporins are recommended
• Avoid azithromycin and clarithromycin due to significant resistance in some U.S. regions 4

Important consideration: Even with confirmed streptococcal infection, the modest benefits of antibiotics (shortening symptoms by approximately 1 day) must be weighed against side effects, effects on microbiota, increased antimicrobial resistance, medicalization, and costs. 1, 5

Step 5: Symptomatic Treatment for All Patients

Ibuprofen or paracetamol (acetaminophen) are strongly recommended for pain relief in all patients with acute sore throat, regardless of etiology. 1, 2

• These are the most effective symptomatic treatments available 1, 3
• Corticosteroids are not routinely recommended, though can be considered in adults with 3-4 Centor criteria 1
• Zinc gluconate is not recommended 1
• Herbal treatments and acupuncture have inconsistent evidence 1

Key Clinical Principles

Antibiotics do NOT prevent complications in low-risk patients: 1, 3

• Prevention of rheumatic fever and acute glomerulonephritis is not an indication for antibiotics in low-risk patients (those without previous rheumatic fever) 1
• Prevention of suppurative complications (quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis) is not a specific indication for antibiotic therapy 1

Most sore throats are self-limiting within 7 days without antibiotics, even when bacterial. 3, 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics for symptom relief in patients with 0-2 Centor criteria—this provides no benefit and increases antimicrobial resistance 1
• Do not treat organisms like E. coli isolated from throat cultures—these represent colonization, not infection 6
• Do not continue empiric antibiotics in severe cases without identifying the underlying cause—life-threatening complications require specific interventions 2
• Do not use broad-spectrum antibiotics empirically—penicillin V remains first-line when antibiotics are indicated 1