What is the appropriate treatment for a patient with a three‑day sore throat, fever, and concurrent upper‑respiratory cold symptoms suggestive of acute viral pharyngitis?

Treatment of Acute Viral Pharyngitis

For a patient with a three-day sore throat, fever, and concurrent upper respiratory cold symptoms (cough, rhinorrhea), antibiotics are not indicated—symptomatic treatment with ibuprofen or acetaminophen is the appropriate management. 1

Rationale: Why This is Viral, Not Bacterial

The presence of concurrent upper respiratory symptoms (cough, rhinorrhea, hoarseness) strongly suggests a viral etiology rather than Group A Streptococcal (GAS) pharyngitis. 1, 2

• Viral pharyngitis accounts for the majority of acute sore throat cases in adults and children 1
• GAS pharyngitis typically presents with abrupt onset of intense sore throat, fever, tonsillar exudates, and tender anterior cervical lymphadenopathy—without cough or rhinorrhea 3
• Testing for GAS is usually not recommended when clinical and epidemiological features strongly suggest a viral etiology (cough, rhinorrhea, hoarseness) 1

Clinical Decision-Making: When to Consider Antibiotics

Use the Centor criteria to assess the likelihood of bacterial pharyngitis: 1, 4

• 1 point each for:
  • History of fever
  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough

Treatment algorithm based on Centor score: 1, 4

• 0-2 points: Do NOT prescribe antibiotics—viral etiology is most likely 1
• 3-4 points: Consider rapid antigen detection test (RADT); antibiotics only if positive 1, 4

In your patient with concurrent cold symptoms (cough, rhinorrhea), the absence of cough criterion is NOT met, making the Centor score low and bacterial pharyngitis unlikely. 4

Recommended Symptomatic Treatment

First-line symptomatic management: 1, 2

• Ibuprofen or acetaminophen (paracetamol) for pain relief and fever control 1
• Adequate hydration with cool liquids 2
• Throat lozenges or salt water gargles for additional comfort 2
• Rest and supportive care 2

Avoid aspirin in children due to risk of Reye syndrome 1

Expected Clinical Course

• Most viral sore throats resolve within 7 days even without treatment 5, 6, 7
• Symptoms typically improve gradually over 1-2 weeks with supportive care alone 2
• Approximately 90% of patients (treated or untreated) are symptom-free by one week 8

When Antibiotics ARE Indicated (Not This Case)

If GAS pharyngitis is confirmed (positive RADT or culture in patients with 3-4 Centor criteria): 1

• First-line: Penicillin V twice or three times daily for 10 days 1
• Alternative: Amoxicillin 50 mg/kg/day in 2 doses (max 1000 mg/day) for 10 days 1
• Penicillin allergy: First-generation cephalosporin for 10 days, clindamycin for 10 days, or azithromycin for 5 days 1

Critical Pitfalls to Avoid

Do not prescribe antibiotics for viral pharyngitis: 1, 2

• Over 60% of adults with sore throat receive unnecessary antibiotics 5
• Antibiotics provide no benefit for viral infections and cause harm through adverse effects, disruption of normal microbiota, and promotion of antimicrobial resistance 1
• Even in confirmed GAS pharyngitis, antibiotics only shorten symptom duration by approximately 8 hours overall and half a day at day 3 8

Avoid amoxicillin/ampicillin if infectious mononucleosis is suspected (posterior cervical lymphadenopathy, rash, systemic symptoms), as these antibiotics cause a characteristic maculopapular rash in 80-90% of EBV-infected patients 2

Red Flags Requiring Urgent Evaluation

Seek immediate evaluation if: 2, 5

• Difficulty swallowing, drooling, or inability to swallow
• Severe neck tenderness or swelling
• Trismus (difficulty opening mouth)
• "Hot potato voice"
• High fever >39°C that persists
• Difficulty breathing
• Unilateral tonsillar swelling with uvular deviation (peritonsillar abscess)

These features suggest serious complications (peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome) requiring imaging and specialist consultation. 2, 5

Follow-Up Recommendations

Reassure the patient: 2, 7

• Viral pharyngitis symptoms typically last up to 2 weeks 2
• Gradual improvement is expected with supportive care alone 2

Return if: 2

• Symptoms worsen rather than improve
• High fever develops (>39°C)
• Severe headache occurs
• Difficulty breathing or swallowing develops
• Symptoms persist beyond 2-3 weeks (warrants re-evaluation for other causes) 5