Management of Sore Throat with Irritation
Symptomatic Treatment Is the Cornerstone for Most Cases
For the vast majority of sore throats—which are viral—offer ibuprofen or paracetamol (acetaminophen) as first-line analgesics to relieve pain and fever. 1 These agents have moderate-strength evidence supporting their efficacy and should be the primary symptomatic intervention. 1 Throat lozenges used every two hours can provide additional comfort, though the evidence base is more limited. 2 Salt water gargles and viscous lidocaine are commonly employed for topical relief, but data supporting their effectiveness remain sparse. 1
Avoid aspirin in children and adolescents due to the risk of Reye syndrome. 1, 3 Corticosteroids provide only minimal symptom reduction (approximately 5 hours of pain relief) and are not recommended for routine use in uncomplicated pharyngitis. 1, 2 Zinc gluconate, herbal remedies, and acupuncture lack consistent evidence and should not be prescribed. 1
When to Test for Group A Streptococcus
Do not test patients who present with clear viral features—cough, rhinorrhea, hoarseness, conjunctivitis, or oral ulcers—because these strongly indicate a viral etiology. 1, 4 Testing is appropriate when patients present with sudden-onset sore throat, fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 1, 2, 5
Age-Specific Testing Strategies
Children and adolescents (ages 5–15): Perform a rapid antigen detection test (RADT) first. 1, 4 If positive (specificity ≥95%), no backup culture is needed. 1 If negative, obtain a throat culture because RADT sensitivity is only 80–90%, missing 10–20% of true infections. 1, 4 This two-step approach is mandatory because children face higher risk of acute rheumatic fever. 1
Adults: A negative RADT alone suffices to rule out Group A Streptococcus; no backup culture is required. 1, 4 Adults have only 5–10% prevalence of streptococcal pharyngitis and virtually zero risk of acute rheumatic fever, making the false-negative rate acceptable. 1, 4
Children under 3 years: Do not routinely test, as streptococcal pharyngitis and acute rheumatic fever are rare in this age group. 1, 4 Testing may be considered if an older sibling has confirmed Group A Streptococcus infection. 4
Antibiotic Therapy: Only for Confirmed Streptococcal Infection
Antibiotics should be prescribed only when Group A Streptococcus is confirmed by positive RADT or throat culture. 1, 4 The primary goal is preventing acute rheumatic fever, not merely shortening symptom duration (antibiotics reduce sore throat by only 1–2 days). 1
First-Line Regimens (10-Day Course Mandatory)
Penicillin V or amoxicillin for 10 days is the definitive first-line treatment, offering proven efficacy, narrow spectrum, zero documented resistance worldwide, and low cost. 1, 3, 6
- Adults: Penicillin V 500 mg twice daily for 10 days, or amoxicillin 50 mg/kg once daily (maximum 1 gram) for 10 days. 1, 6
- Children ≥27 kg: Penicillin V 500 mg twice daily for 10 days. 1, 6
- Children <27 kg: Penicillin V 250 mg twice daily for 10 days. 1, 6
- Intramuscular option (if adherence uncertain): Benzathine penicillin G 1.2 million units (≥27 kg) or 600,000 units (<27 kg) as a single dose. 1, 6
A full 10-day course is essential to achieve maximal pharyngeal eradication and prevent acute rheumatic fever; shortening the course by even 2–3 days markedly increases treatment failure and rheumatic fever risk. 1, 3, 6 Treatment initiated within 9 days of symptom onset still effectively prevents acute rheumatic fever. 1, 4
Penicillin-Allergic Patients
For non-immediate (delayed) penicillin allergy: First-generation cephalosporins are preferred alternatives with strong, high-quality evidence. 1, 3 Cephalexin 500 mg twice daily for 10 days (adults) or 20 mg/kg twice daily (children, maximum 500 mg per dose) for 10 days. 1, 3 Cross-reactivity risk is only 0.1% with delayed reactions. 1, 3
For immediate/anaphylactic penicillin allergy: All beta-lactams must be avoided due to up to 10% cross-reactivity. 1, 3
Clindamycin (preferred): 300 mg three times daily for 10 days (adults) or 7 mg/kg three times daily (children, maximum 300 mg per dose) for 10 days. 1, 3, 6 Resistance is only ~1% in the United States, and clindamycin demonstrates superior eradication even in chronic carriers. 1, 3
Azithromycin (acceptable alternative): 500 mg once daily for 5 days (adults) or 12 mg/kg once daily (children, maximum 500 mg) for 5 days. 1, 3, 6 Azithromycin is the only antibiotic requiring just 5 days due to its prolonged tissue half-life. 1, 3, 6 However, macrolide resistance ranges from 5–8% in the United States and varies geographically. 1, 3
Clarithromycin: 250 mg twice daily for 10 days (adults) or 7.5 mg/kg twice daily (children, maximum 250 mg per dose) for 10 days. 1, 3 Similar resistance concerns as azithromycin. 1, 3
Critical Pitfalls to Avoid
Do not prescribe antibiotics based solely on clinical appearance (exudates, white patches) without laboratory confirmation, as these findings occur in both viral and bacterial infections. 1, 4 Clinical scoring alone has low positive predictive value (40–60% even with high scores). 4
Do not test or treat asymptomatic household contacts; up to one-third may be asymptomatic carriers, and prophylactic treatment does not reduce subsequent infection rates. 1, 4
Do not shorten antibiotic courses below 10 days (except azithromycin's 5-day regimen), as this dramatically increases treatment failure and rheumatic fever risk. 1, 3, 6
Do not order routine post-treatment throat cultures for asymptomatic patients who completed therapy; positive results often reflect carrier status rather than treatment failure. 1, 4
Do not use broad-spectrum cephalosporins (cefdinir, cefpodoxime) when narrow-spectrum first-generation agents are appropriate, as they are more expensive and promote antibiotic resistance. 1, 3
When Symptoms Persist or Worsen
Reassess patients within 48–72 hours if there is no clinical improvement, as this may indicate non-compliance, an alternative diagnosis, or suppurative complications (peritonsillar abscess, cervical lymphadenitis). 1, 4 For documented treatment failures after a fully adhered 10-day course, switch to clindamycin, which achieves substantially higher eradication rates in chronic carriers and persistent infections. 1, 3