How do I manage a severe sore throat, including diagnosing bacterial versus viral infection and selecting appropriate antibiotic and supportive therapy?

Management of Severe Sore Throat

For severe sore throat, first rule out life-threatening complications (peritonsillar abscess, retropharyngeal abscess, epiglottitis, Lemierre syndrome), then use the Centor score to guide testing and treatment: patients with 3-4 criteria should receive rapid antigen testing for Group A Streptococcus, and if positive, treat with penicillin V 250 mg twice or three times daily for 10 days, while all patients should receive ibuprofen or paracetamol for symptom relief. 1

Step 1: Identify Red Flags for Life-Threatening Complications

Before considering routine bacterial pharyngitis, immediately evaluate for severe complications if the patient presents with: 1

• Severe difficulty swallowing or drooling
• Neck tenderness, swelling, or trismus
• "Hot potato voice"
• Respiratory distress

These findings require urgent imaging and specialist consultation, not empiric antibiotics. 2

Step 2: Apply the Centor Scoring System

Calculate the Centor score (1 point for each criterion): 3, 1

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

Interpretation and action based on score:

• 0-2 criteria: Viral pharyngitis is most likely—do NOT test or treat with antibiotics. Provide symptomatic treatment only. 3, 1
• 3-4 criteria: Higher probability of Group A Streptococcus—proceed to rapid antigen detection test (RADT). 3, 1

This scoring approach is critical because 65-85% of sore throats are viral, and antibiotics provide no benefit for viral infections. 4

Step 3: Diagnostic Testing (Only for Centor 3-4)

Use rapid antigen detection testing (RADT) in patients with 3-4 Centor criteria. 3

• If RADT is positive: Treat with antibiotics
• If RADT is negative: No throat culture is necessary after negative RADT in both children and adults 3
• Do NOT routinely use biomarkers like C-reactive protein or procalcitonin 3

Common pitfall to avoid: Do not perform throat cultures routinely or treat organisms like E. coli isolated from throat swabs, as these represent colonization rather than true infection. 2

Step 4: Antibiotic Therapy (Only for Confirmed Group A Streptococcus)

If Group A Streptococcus is confirmed by RADT in patients with 3-4 Centor criteria, prescribe penicillin V 250 mg twice or three times daily for 10 days. 3, 1, 4

Key principles for antibiotic use:

• Antibiotics should NOT be prescribed to prevent rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous rheumatic fever history) 3, 1
• Antibiotics do NOT prevent suppurative complications like quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis in most cases 3
• The modest symptom relief benefits in confirmed streptococcal infection must be weighed against side effects, antimicrobial resistance, and costs 3, 4

Step 5: Symptomatic Treatment (For ALL Patients)

Either ibuprofen or paracetamol (acetaminophen) are strongly recommended for pain relief in all patients with acute sore throat, regardless of etiology. 3, 1, 4

Corticosteroids:

• NOT routinely recommended
• Can be considered in adults with severe presentations (3-4 Centor criteria) when used in conjunction with antibiotic therapy 3, 1

NOT recommended:

• Zinc gluconate 3
• Herbal treatments or acupuncture (inconsistent evidence) 3

Clinical Nuances and Evidence Quality

The 2012 Clinical Microbiology and Infection guideline provides the foundational framework, with more recent guidance from multiple societies (American Academy of Family Physicians, Infectious Diseases Society of America, American College of Physicians) reinforcing these principles. 3, 1, 4

Critical distinction: Most sore throats are self-limiting within 7 days without antibiotics, even when bacterial. 2, 4 The goal is to identify the minority of patients who will benefit from antibiotics while avoiding unnecessary treatment in the majority with viral infections.

Seasonal consideration: Group A Streptococcus peaks during winter and early spring (November-May), with rhinovirus being the most common viral cause overall. 4, 5