What is the appropriate management for an acute sore throat that appears viral (gradual onset, cough, rhinorrhea, hoarseness, conjunctivitis, low‑grade or no fever, no tender anterior cervical nodes or tonsillar exudates)?

Management of Viral Pharyngitis

For acute sore throat with viral features (gradual onset, cough, rhinorrhea, hoarseness, conjunctivitis, low-grade or no fever, no tender anterior cervical nodes or tonsillar exudates), antibiotics should not be prescribed; management consists of symptomatic therapy only. 1

Do Not Test or Treat with Antibiotics

• Patients presenting with cough, rhinorrhea, hoarseness, or conjunctivitis should not undergo testing for Group A Streptococcus because these features strongly indicate viral etiology. 1
• The presence of cough is particularly important—it effectively excludes bacterial pharyngitis and points toward viral infection. 2
• Discrete oral ulcers or ulcerative stomatitis are also characteristic of viral causes and argue against bacterial infection. 3
• Testing in the presence of obvious viral features leads to over-diagnosis of asymptomatic streptococcal carriers and unnecessary antibiotic use. 2

Symptomatic Treatment Recommendations

First-Line Analgesics

• Either ibuprofen or paracetamol (acetaminophen) are recommended for relief of acute sore throat symptoms. 1, 2
• These agents provide effective pain and fever relief without the risks associated with antibiotics. 4

Additional Symptomatic Measures

• Throat lozenges can provide comfort as an adjunctive measure. 2
• Adequate hydration, warm saline gargles, and rest are supportive measures. 3
• Combination antihistamine-analgesic-decongestant products may offer symptom relief, with 1 out of 4 patients experiencing significant benefit. 1
• Other options include inhaled ipratropium bromide, inhaled cromolyn sodium, and antitussives, though data supporting specific therapies are limited. 1

Expected Clinical Course

• Patients should be advised that viral pharyngitis symptoms typically last up to 2 weeks and are self-limited. 1
• The mean duration of acute sore throat is approximately 7 days. 4
• Patients should be instructed to follow up if symptoms worsen or exceed the expected recovery time. 1

Why Antibiotics Are Not Indicated

• Antibiotics provide no benefit for viral pharyngitis and lead to significantly increased risk for adverse effects. 1
• Even when antibiotics are used for confirmed bacterial pharyngitis, they shorten sore throat duration by only 1-2 days, with a number needed to treat of 6 at 3 days and 21 at 1 week. 2
• The vast majority of acute pharyngitis cases are viral; Group A Streptococcus accounts for only 5-15% of adult cases and 20-30% of pediatric cases. 2, 3
• Antibiotics do not prevent post-streptococcal glomerulonephritis. 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on clinical appearance alone without laboratory confirmation. White patches and tonsillar exudates can occur with viral infections and do not reliably distinguish bacterial from viral causes. 2, 3
• Do not test or treat asymptomatic household contacts, as up to one-third may be asymptomatic carriers and prophylactic treatment does not reduce subsequent infection rates. 2
• Avoid labeling patients as requiring antibiotics simply because they present to medical care; most viral pharyngitis cases resolve without intervention. 1

When to Reconsider the Diagnosis

• If symptoms persist beyond 10 days, worsen significantly, or the patient develops high fever (>39°C), severe symptoms, or signs of systemic toxicity, consider alternative diagnoses or suppurative complications. 1, 2
• Development of tender anterior cervical lymphadenopathy, tonsillar exudates, or absence of viral features should prompt reconsideration and possible testing for Group A Streptococcus. 1