What is the recommended management for a hospitalized patient presenting with a sore throat, including assessment for airway compromise, diagnosis of streptococcal infection, and appropriate antibiotic and supportive therapy?

Management of Sore Throat in the Hospital

For hospitalized patients with sore throat, first assess for airway compromise and severe systemic infection, then use the Centor score to guide testing and treatment decisions—patients with 0-2 criteria receive symptomatic care only with ibuprofen or acetaminophen, while those with 3-4 criteria should undergo rapid antigen detection testing and receive antibiotics only if positive. 1

Initial Assessment: Exclude Red Flags

Immediately evaluate for airway compromise and severe systemic infection before proceeding with routine sore throat management, as these require urgent intervention. 2

Key red flags requiring immediate escalation include:

• Severe immunosuppression (active chemotherapy, HIV with low CD4 count, transplant recipients) 2
• Signs of airway obstruction (stridor, drooling, inability to swallow secretions, severe trismus) 2
• Severe systemic infection (sepsis, hypotension, altered mental status) 2

If any red flags are present, standard outpatient sore throat algorithms do not apply—these patients require specialist consultation and broader diagnostic workup. 2

Risk Stratification Using Centor Score

Apply the Centor scoring system to determine the probability of Group A streptococcal infection, assigning one point for each of the following four criteria: 1, 3

• Fever by history 3
• Tonsillar exudates 3
• Tender anterior cervical lymphadenopathy 3
• Absence of cough 3

The presence of cough, rhinorrhea, hoarseness, conjunctivitis, or oral ulcers strongly suggests viral etiology and argues against bacterial pharyngitis. 1, 4

Probability of Group A Streptococcal Infection by Score:

• Score 0-1: 2.5-12% probability 3
• Score 2: 11-23% probability 3
• Score 3: 28-38% probability 3
• Score 4: 51-57% probability 3

Diagnostic Testing Strategy

For Patients with Centor Score 0-2 (Low Risk):

Do not perform rapid antigen detection testing or throat culture—the probability of streptococcal infection is too low to justify testing. 1, 4

For Patients with Centor Score 3-4 (Higher Risk):

Perform a rapid antigen detection test (RADT) to confirm Group A streptococcal infection before prescribing antibiotics. 1, 5

• If RADT is positive: Proceed with antibiotic therapy 1
• If RADT is negative in adults: No backup throat culture is needed—a negative RADT alone is sufficient to rule out streptococcal pharyngitis 1, 4
• If RADT is negative in children/adolescents: Obtain a backup throat culture because RADT sensitivity is only 80-90% in pediatric populations 1, 4

The specificity of RADT is ≥95%, making false-positive results rare, so positive tests do not require culture confirmation. 1, 4

Routine biomarkers such as C-reactive protein or procalcitonin are not necessary in the assessment of acute sore throat. 1

Antibiotic Therapy for Confirmed Streptococcal Pharyngitis

First-Line Treatment:

Penicillin or amoxicillin for 10 days is the definitive first-line regimen due to narrow spectrum, proven efficacy, low cost, and effectiveness in preventing acute rheumatic fever. 1, 5

Specific dosing:

• Penicillin V: 250 mg 2-3 times daily for patients <27 kg; 500 mg 2-3 times daily for patients ≥27 kg 1, 4
• Amoxicillin: 50 mg/kg once daily (maximum 1 g) 1, 5
• Benzathine penicillin G (IM): Single dose of 600,000 U for patients <27 kg; 1,200,000 U for patients ≥27 kg 4

For Penicillin-Allergic Patients:

Non-anaphylactic allergy:

• First-generation cephalosporin (cephalexin or cefadroxil) for 10 days 1, 5

Anaphylactic or immediate-type hypersensitivity:

• Clindamycin: 20 mg/kg/day divided three times daily (maximum 1.8 g/day) for 10 days 1, 4, 5
• Clarithromycin: 15 mg/kg/day divided twice daily for 10 days 1, 5
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 5

Avoid broad-spectrum cephalosporins (cefixime, cefdinir, cefpodoxime) as they are more expensive and promote antibiotic resistance without added benefit. 1

Macrolide resistance rates in the United States are approximately 5-8%, which should be considered when selecting alternatives. 1, 5

Symptomatic Management

Analgesics (For All Patients):

Either ibuprofen or acetaminophen (paracetamol) are recommended for relief of acute sore throat symptoms, fever control, and pain management. 1

Avoid aspirin in children due to the risk of Reye syndrome. 1

Corticosteroids:

Corticosteroids are not routinely recommended for treatment of sore throat, though they may be considered in adult patients with severe presentations (Centor score 3-4) in conjunction with antibiotics. 1

The actual benefit is minimal—approximately 5 hours reduction in pain duration—and does not justify routine use given potential adverse effects. 1

Not Recommended:

• Zinc gluconate is not recommended 1
• Herbal treatments and acupuncture have inconsistent evidence 1

Management When Testing is Negative

Withhold antibiotics entirely when streptococcal testing is negative—provide only symptomatic therapy because the vast majority of these cases are viral and self-limiting. 1, 4

Approximately 70% of patients with sore throat receive antibiotics, yet only 20-30% of pediatric patients and 5-10% of adult patients actually have Group A streptococcal pharyngitis, indicating massive overuse. 4

Antibiotics should not be used in patients with Centor scores 0-2 to relieve symptoms, as the modest benefits do not outweigh side effects, effects on the microbiota, increased resistance, and costs. 1

Rationale for Antibiotic Stewardship

Antibiotics shorten symptom duration by only 1-2 days with a number needed to treat of 6 at 3 days and 21 at 1 week. 4, 6

Sore throat should not be treated with antibiotics to prevent rheumatic fever and acute glomerulonephritis in low-risk patients (those with no previous history of rheumatic fever). 1

The prevention of suppurative complications is not a specific indication for antibiotic therapy in sore throat—clinicians do not need to treat most cases to prevent quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, or acute sinusitis. 1

Treatment initiated up to 9 days after symptom onset still effectively prevents acute rheumatic fever, so there is no need to prescribe antibiotics empirically while awaiting culture results. 4

Special Populations and Circumstances

Children Under 3 Years:

Diagnostic testing for Group A streptococcus is not indicated in children <3 years old because acute rheumatic fever is rare and the incidence of streptococcal pharyngitis is uncommon in this age group. 1, 4

Selected children <3 years with risk factors (such as an older sibling with confirmed GAS infection) may be considered for testing. 1

Household Contacts:

Do not test or treat asymptomatic household contacts—up to one-third of household members may be asymptomatic GAS carriers, and prophylactic treatment does not reduce subsequent infection rates. 1, 4

Follow-Up Testing:

Routine follow-up throat cultures or rapid tests after completing antibiotic treatment are not recommended in asymptomatic patients, as positive post-treatment tests often reflect carrier status rather than treatment failure. 1, 4

Common Pitfalls to Avoid

Do not prescribe antibiotics based on clinical appearance alone—white patches and tonsillar exudates occur with both viral and bacterial infections and cannot reliably distinguish between them. 4

Do not order backup throat cultures in adults with negative RADT—this wastes resources and is not indicated. 4

Do not use broad-spectrum antibiotics when narrow-spectrum options are effective—this increases resistance and side effects without added benefit. 1, 5

Recognize that recurrent pharyngitis may represent chronic GAS carriage with superimposed viral infections rather than repeated true streptococcal infections. 1, 4