What is the recommended management of an acute sore throat, including symptomatic measures and indications for antibiotic therapy?

Management of Acute Sore Throat

For patients with acute sore throat, provide symptomatic treatment with ibuprofen or acetaminophen as first-line therapy, and reserve antibiotics exclusively for confirmed Group A Streptococcus infection in patients with 3–4 Centor criteria after positive rapid antigen detection testing. 1, 2

Initial Assessment and Risk Stratification

Red-Flag Symptoms Requiring Urgent Evaluation

Immediately assess for life-threatening complications before considering routine management 1, 2:

• Difficulty swallowing or drooling 1
• Neck tenderness or swelling 1
• Unilateral tonsillar swelling with uvular deviation 1
• "Hot-potato" voice 1
• Trismus 3

These signs may indicate peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome and warrant immediate imaging and specialist consultation 1, 2, 4.

Clinical Scoring for Bacterial Probability

Apply the Modified Centor criteria to determine likelihood of Group A Streptococcus (GAS) pharyngitis 1, 2:

• Fever by history (1 point) 2
• Tonsillar exudates (1 point) 2
• Tender anterior cervical adenopathy (1 point) 2
• Absence of cough (1 point) 2

Interpretation:

• 0–2 points: Viral pharyngitis; symptomatic treatment only, no testing or antibiotics 5, 2
• 3–4 points: 51–53% probability of GAS; perform rapid antigen detection test (RADT) 1, 2

Diagnostic Testing Strategy

When to Test

• Perform RADT only in patients with 3–4 Centor criteria 1, 2
• Do not test patients with 0–2 Centor criteria 5, 2
• A positive RADT is diagnostic and does not require confirmatory culture 1

Age-Specific Testing Considerations

• Adolescents: Follow negative RADT with backup throat culture due to lower test sensitivity 1
• Adults: Routine backup culture after negative RADT is not required 1

Critical Pitfall: Carrier State Recognition

Up to 20% of asymptomatic adolescents may be GAS carriers during winter/spring 1. A positive test in the presence of viral symptoms (cough, rhinorrhea, conjunctivitis) likely reflects carriage rather than active infection and should not be treated 1, 3.

Symptomatic Management (All Patients)

First-Line Analgesics

Ibuprofen or acetaminophen (paracetamol) are strongly recommended for pain relief in all patients with acute sore throat, regardless of etiology 1, 2, 6. Evidence suggests ibuprofen shows the best benefit-risk profile among systemic analgesics 7.

Additional Symptomatic Measures

• Throat lozenges may provide additional relief 1, 2
• Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg) can be recommended for first-line treatment, with ambroxol having the best documented benefit-risk profile 7
• Avoid aspirin in adolescents due to risk of Reye syndrome 1

Expected Clinical Course

• Most sore throats resolve within 7 days without antibiotics, even when bacterial 2, 6
• Streptococcal pharyngitis symptoms usually resolve within 3–4 days even without antibiotics 1
• Untreated patients may experience throat soreness persisting 1–2 days longer than those treated 1

Antibiotic Therapy (Confirmed GAS Only)

Indications for Antibiotics

Prescribe antibiotics only after confirming GAS infection by positive RADT in patients with 3–4 Centor criteria 1, 2. Over 60% of adults with sore throat receive unnecessary antibiotics 1.

First-Line Antibiotic Regimen

Penicillin V 250 mg orally twice or three times daily for 10 days 5, 1, 2. Penicillin remains the treatment of choice due to proven efficacy, safety, narrow spectrum, low cost, and absence of resistance development over five decades 5.

Alternative Agents

• Amoxicillin may be used in younger children for taste considerations and availability as suspension 5
• Avoid amoxicillin in older children due to risk of severe rash with Epstein-Barr virus infection 5
• Clarithromycin as alternative for penicillin-allergic patients 6

Duration of Therapy

A full 10-day regimen is required for adequate GAS eradication 1. Abbreviated courses (e.g., 5 days) lack sufficient evidence 1. Although some evidence suggests 5–7 days may be acceptable 6, the most recent high-quality guidelines emphasize 10 days 1.

Benefits and Limitations of Antibiotic Therapy

• Symptom reduction: Antibiotics shorten symptom duration by 1–2 days, with number needed to treat of 6 at day 3 and 21 at day 7 1
• Primary goals: Prevention of acute rheumatic fever, peritonsillar abscess (quinsy), and reduction of transmission 1
• Suppurative complications: Antibiotics reduce acute otitis media (Peto OR 0.21) and quinsy (Peto OR 0.16) within 14 days to 2 months 8
• Acute rheumatic fever: Antibiotics reduce incidence (Peto OR 0.36), though overall prevalence is now very low 8

Delayed Prescribing Strategy

Delayed prescribing (more than 48 hours after initial consultation) is a valid option 5. No significant differences in complication rates were found between delayed antibiotics, immediate antibiotics, or no antibiotics 5.

Antibiotic Stewardship: Critical Pitfalls to Avoid

• Do not prescribe empiric antibiotics based solely on clinical features without microbiological confirmation 1, 2
• Do not use abbreviated penicillin courses (e.g., 5 days); a full 10-day regimen is required 1
• Do not test or treat asymptomatic household contacts unless a specific outbreak is identified 1
• Do not perform routine post-treatment testing in asymptomatic patients, as it may detect carriage rather than active infection 1
• Do not treat organisms like E. coli isolated from throat cultures, as they represent colonization, not infection 3
• Do not use local antibiotics or antiseptics due to mainly viral origin and lack of efficiency data 7

Special Consideration: Fusobacterium necrophorum

Fusobacterium necrophorum accounts for 10–20% of endemic pharyngitis in adolescents and can cause Lemierre syndrome 1. Remain vigilant for severe or worsening illness despite appropriate therapy, particularly in adolescents with persistent or deteriorating symptoms 1, 4.