Management of Sore Throat in Adults and Adolescents
For adults and adolescents with sore throat, use the Centor criteria to guide testing and treatment: patients with 0-2 criteria should receive symptomatic treatment only with ibuprofen or acetaminophen and no antibiotics; those with 3-4 criteria require rapid antigen testing (RADT) with treatment only if positive. 1, 2, 3
Risk Stratification Using Centor Criteria
Calculate the Centor score by assigning one point for each of the following 1, 2, 3:
- Fever (documented temperature or history of fever)
- Tonsillar exudates (patchy or confluent)
- Tender anterior cervical lymphadenopathy
- Absence of cough
Probability of Group A Streptococcal (GAS) Infection by Score
| Centor Score | GAS Probability | Management Strategy |
|---|---|---|
| 0-1 | 1-10% | No testing, no antibiotics [1,2,3] |
| 2 | 11-17% | Consider testing based on clinical judgment [2,3] |
| 3-4 | 28-53% | Perform RADT; treat only if positive [1,2,3] |
Diagnostic Testing Approach
For patients with 3-4 Centor criteria: Perform rapid antigen detection testing immediately, which has >95% specificity and ≥90% sensitivity. 1, 2
- If RADT is positive: Treat with antibiotics immediately—no throat culture needed. 1, 2
- If RADT is negative in adolescents: Confirm with backup throat culture before treating. 1, 2
- If RADT is negative in adults: No backup culture is necessary under usual circumstances. 1
Do not test patients with features strongly suggesting viral etiology: cough, rhinorrhea, hoarseness, conjunctivitis, oral ulcers, or diarrhea. 1, 2
Antibiotic Treatment (Only When Indicated)
First-line therapy: Penicillin V 250 mg orally twice or three times daily for 10 days. 1, 2, 4, 5
- Alternative: Amoxicillin is equally effective and more palatable. 4
- For penicillin allergy (non-anaphylactic): First-generation cephalosporin. 1, 5
- For anaphylactic penicillin allergy: Clindamycin, erythromycin, or other macrolide (note: significant resistance to azithromycin and clarithromycin exists in some U.S. regions). 1, 5
The full 10-day course is essential—shorter regimens lack sufficient evidence. 2, 4
Symptomatic Management for All Patients
Ibuprofen or acetaminophen (paracetamol) are strongly recommended for pain relief and fever reduction regardless of etiology. 1, 2, 6
- These are the most effective symptomatic treatments available. 1, 2
- Aspirin is contraindicated in children and adolescents. 2
Corticosteroids are not routinely recommended. They may be considered only in adults with severe presentations (3-4 Centor criteria) in conjunction with antibiotics, but evidence of benefit is limited and smaller in typical primary care populations. 1
Zinc gluconate is not recommended due to conflicting results and increased adverse effects. 1
Herbal treatments and acupuncture have inconsistent evidence and cannot be reliably recommended. 1, 2
Critical Pitfalls to Avoid
Do not prescribe antibiotics for patients with 0-2 Centor criteria. Nationally, up to 70% of patients with sore throats receive antibiotics, yet only 20-30% have GAS pharyngitis. 1, 2 The modest symptom reduction (approximately one day shorter duration) does not justify the risks of side effects, antimicrobial resistance, and costs. 2, 6
Do not prescribe antibiotics to prevent complications in low-risk patients. Rheumatic fever and acute glomerulonephritis are extremely rare in developed countries and should not drive treatment decisions in patients without prior rheumatic fever. 2, 3, 6
Do not treat asymptomatic GAS carriers. Up to 20% of school-aged children carry GAS asymptomatically during winter and spring with extremely low risk of complications or transmission. 2, 3 Neither RADTs nor throat cultures distinguish acute infection from asymptomatic carriage. 1
Do not assume all positive tests require treatment. When carriers develop concurrent viral pharyngitis, the positive GAS test reflects colonization, not the cause of symptoms. 2
When to Reevaluate
Patients should return if 5:
- Symptoms worsen after appropriate antibiotic initiation
- Symptoms persist 5 days after starting treatment
- Severe difficulty swallowing or breathing develops 2
Special Considerations
Delayed prescribing is a valid evidence-based strategy that reduces antibiotic use without increasing complication rates in patients with 2-3 Centor criteria. 6, 7 Discuss with patients that most sore throats are viral, self-limiting within 7 days, and do not require antibiotics. 2
The diagnostic accuracy of Centor criteria is modest (area under ROC curve 0.62), but it remains the best validated tool for risk stratification in primary care. 8 Clinical judgment alone greatly overestimates the probability of GAS infection. 1