What is the appropriate evaluation and management for a patient presenting with a sore throat?

Evaluation and Management of Sore Throat

Use the Centor criteria to risk-stratify patients, then test only those with 2 or more criteria using a rapid antigen detection test (RADT), and reserve antibiotics exclusively for patients with 3-4 criteria who test positive for Group A Streptococcus. 1

Initial Clinical Assessment

Begin by identifying red flags that require urgent evaluation:

• Immediately evaluate for life-threatening conditions if the patient presents with difficulty swallowing, drooling, or neck swelling, which suggests peritonsillar abscess, parapharyngeal abscess, or epiglottitis 1
• Severe unilateral throat pain with trismus and uvular deviation indicates peritonsillar abscess (quinsy) 2
• Persistent fever with neck pain in adolescents/young adults requires consideration of Lemierre syndrome (suppurative thrombophlebitis of internal jugular vein) 2, 1

Risk Stratification Using Centor Criteria

Apply the Centor scoring system, which includes four criteria (1 point each): 1

• Fever (temperature >38°C)
• Tonsillar or pharyngeal exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough

Clinical features that strongly suggest viral etiology (do not test or treat these patients): 3, 2

• Conjunctivitis, cough, hoarseness, coryza, diarrhea, anterior stomatitis, discrete ulcerative lesions, or viral exanthem

Testing Strategy Based on Centor Score

Score 0-1: No testing needed; viral etiology is most likely—provide symptomatic treatment only 1

Score 2: Consider testing with RADT or throat culture 1

Score 3-4: Perform RADT before prescribing antibiotics 3, 1

Important Testing Principles

• RADT is the preferred initial test and does not require confirmatory throat culture after a negative result in both adults and children 3, 1
• Throat culture is not necessary for routine diagnosis but can be used as an alternative to RADT 1
• Do not routinely use biomarkers such as C-reactive protein or procalcitonin in the assessment of acute sore throat 3, 1

Symptomatic Treatment (All Patients)

Either ibuprofen or paracetamol are recommended for relief of acute sore throat symptoms 3, 4

• Both show equivalent efficacy and safety for short-term use 4
• For patients with renal impairment, paracetamol is the safer choice 4

Antibiotic Decision-Making

Antibiotics should NOT be used in patients with 0-2 Centor criteria to relieve symptoms 3, 4

For patients with 3-4 Centor criteria:

• Perform RADT before prescribing antibiotics 3, 1
• Discuss modest benefits versus side effects, antimicrobial resistance, and costs with the patient 3
• The modest benefits observed in RADT-positive patients with 3-4 Centor criteria must be weighed against harms 3

When Antibiotics Are Indicated

Penicillin V is the first-choice agent, given twice or three times daily for 10 days 3, 4, 5

• There is insufficient evidence to support shorter treatment duration 3
• For penicillin-allergic patients: first-generation cephalosporins, clindamycin, or macrolides can be used 2
• Note significant resistance to azithromycin and clarithromycin in some parts of the United States 5

What Antibiotics Do NOT Prevent

Critical understanding for antibiotic stewardship:

• Antibiotics do not prevent suppurative complications (quinsy, otitis media, sinusitis, mastoiditis) in most cases 3, 4
• Antibiotics do not prevent rheumatic fever or glomerulonephritis in low-risk patients without prior rheumatic fever history 3, 4
• The prevention of these complications is not a specific indication for antibiotic therapy 3

Treatments NOT Recommended

• Zinc gluconate is not recommended for sore throat 3, 4
• Herbal treatments and acupuncture have inconsistent evidence 3, 4
• Corticosteroids are not routinely recommended, though they can be considered in severe presentations (3-4 Centor criteria) in conjunction with antibiotics 3, 4
• Steroids are not recommended for symptomatic treatment alone 5

Common Pitfalls to Avoid

• Do not test patients with clear viral symptoms such as cough, rhinorrhea, or conjunctivitis, as this leads to false-positive results in carriers and unnecessary antibiotic use 1
• Do not prescribe antibiotics based on clinical features alone without microbiological confirmation, as clinical features cannot reliably distinguish Group A Streptococcus from viral pharyngitis 1
• Group A Streptococcus accounts for only 15-30% of pharyngitis in children and 5-15% in adults, yet 60% or more adults seeking care are prescribed antibiotics 2, 5
• Chronic carriers (10.9% in children ≤14 years, 2.3% in adults 15-44 years) with intercurrent viral infections are difficult to differentiate from acute infection 2

Follow-Up

Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment should be reevaluated 5