What are the recommended treatments for a patient experiencing throat pain?

Treatment of Throat Pain

For most patients with throat pain, ibuprofen or paracetamol (acetaminophen) should be the primary treatment, with antibiotics reserved only for those with severe presentations (3-4 Centor criteria) who have confirmed or highly suspected bacterial infection. 1

Initial Symptomatic Management

All patients should receive analgesics as first-line therapy:

• Ibuprofen or paracetamol are equally recommended for relief of acute sore throat symptoms with the highest level of evidence (A-1). 1
• Research suggests ibuprofen may have the best benefit-risk profile among available analgesics. 2
• Dosing: Ibuprofen 400-600mg every 6-8 hours as needed, or acetaminophen 500-1000mg every 6 hours as needed. 3

Local anesthetics can be considered as adjunctive therapy:

• Lidocaine (8mg), benzocaine (8mg), or ambroxol (20mg) lozenges have confirmed efficacy in clinical trials, with ambroxol showing the best documented benefit-risk profile. 2

Risk Stratification Using Centor Criteria

Before considering antibiotics, assess the patient using Centor criteria (1 point each): 1

• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Fever
• Absence of cough

Clinical decision algorithm based on score:

• 0-2 Centor criteria: Do NOT prescribe antibiotics. These patients have low likelihood of bacterial infection and antibiotics provide no benefit. 1, 4
• 3-4 Centor criteria: Consider rapid antigen testing (RAT) or throat culture. If positive or testing unavailable, discuss potential modest benefits versus risks with patient. 1

When Antibiotics Are Indicated

Antibiotics should only be prescribed for patients with 3-4 Centor criteria AND confirmed or highly suspected Group A streptococcal infection: 1

• First-line: Penicillin V 250mg twice or three times daily for 10 days (A-1 evidence). 1, 4
• Alternative: Amoxicillin for patients who prefer less frequent dosing. 5, 6
• For penicillin allergy (non-anaphylactic): First-generation cephalosporins. 6
• For anaphylactic penicillin allergy: Use clarithromycin, though note significant resistance exists in some U.S. regions to azithromycin and clarithromycin. 6

Critical caveat: Even in confirmed bacterial pharyngitis, antibiotics only modestly shorten symptom duration and must be weighed against side effects, microbiota disruption, antimicrobial resistance, and costs. 1, 4

What Antibiotics Do NOT Accomplish

Antibiotics should NOT be prescribed to prevent complications in low-risk patients: 1

• Do not prevent rheumatic fever or acute glomerulonephritis in patients without previous rheumatic fever history (A-1 evidence). 1, 4
• Do not prevent suppurative complications such as quinsy (peritonsillar abscess), acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis in most cases (A-1 to A-3 evidence). 1, 4

Role of Corticosteroids

Corticosteroids are NOT routinely recommended but can be considered in specific circumstances: 1, 7

• Only for adults with severe presentations (3-4 Centor criteria) in conjunction with antibiotic therapy. 1, 7
• Dosing: Single oral dose of dexamethasone 10mg. 7
• The benefit is modest and may be considerably smaller in typical primary care populations where most patients do not have severe sore throat. 7
• No benefit demonstrated in children. 7

Diagnostic Testing Approach

Rapid antigen testing (RAT) should be targeted, not routine: 1

• Use RAT only in patients with 3-4 Centor criteria where bacterial infection is more likely. 1
• Do NOT use RAT in patients with 0-2 Centor criteria as testing is unnecessary. 1, 4
• If RAT is performed and negative, throat culture is NOT necessary in adults. 1
• In children and adolescents, throat culture is recommended after negative RAT. 6
• Routine throat culture is not necessary for diagnosis. 1

Treatments to AVOID

The following have no role in routine sore throat management:

• Zinc gluconate: Not recommended (B-2 evidence). 1, 4
• Herbal treatments and acupuncture: Inconsistent evidence (C-1 to C-3). 1, 4
• Biomarkers (CRP, procalcitonin): Not necessary for routine assessment (C-3 evidence). 1
• Local antibiotics or antiseptics: Should not be recommended due to mainly viral origin and lack of efficacy data. 2

Red Flags Requiring Immediate Evaluation

Refer urgently if patient develops: 3

• Severe difficulty swallowing or breathing
• Unilateral tonsillar swelling with uvular deviation (peritonsillar abscess)
• Drooling or muffled voice
• High fever with severe pharyngitis that is progressively worsening

Patient Education Points

Educate all patients that: 4, 8

• Most sore throats are viral and self-limiting within 7 days. 4, 8
• Mean duration is 7 days regardless of treatment. 8
• Antibiotics do not help viral infections and have potential harms. 4, 8
• Symptomatic treatment with ibuprofen or paracetamol is the most effective approach for symptom relief. 4, 8

Common Pitfall to Avoid

The most significant pitfall is antibiotic overprescription: Nationally, up to 70% of patients with sore throats receive antibiotics, while only 20-30% are likely to have bacterial pharyngitis. 4 This occurs because physicians often greatly overestimate the probability of bacterial infection. 4 Use clinical scoring systems consistently to avoid this error. 1