How should I manage a patient presenting with sore throat and irritation without fever?

Management of Sore Throat with Irritation Without Fever

For a patient with sore throat and irritation without fever, symptomatic treatment with ibuprofen or paracetamol is recommended, and antibiotics should not be prescribed, as the absence of fever makes bacterial infection highly unlikely. 1, 2

Initial Assessment Using Clinical Scoring

The absence of fever is a critical finding that substantially reduces the likelihood of Group A streptococcal infection:

• Apply the Centor criteria to stratify risk: The criteria include (1) fever by history, (2) tonsillar exudates, (3) tender anterior cervical lymphadenopathy, and (4) absence of cough, with each criterion worth 1 point. 3, 2
• Without fever, the patient automatically scores ≤3 points maximum, placing them in the low-to-moderate risk category where antibiotics provide no meaningful benefit. 1, 2
• Patients scoring 0-2 Centor criteria should not receive antibiotics, as the likelihood of bacterial infection is extremely low and treatment does not improve outcomes. 1, 2

Red Flag Assessment

Before proceeding with symptomatic management alone, briefly assess for severe complications that require urgent evaluation:

• Look for unilateral tonsillar swelling, uvular deviation, trismus, or "hot potato voice" suggesting peritonsillar abscess. 4
• Assess for neck stiffness, neck swelling, or drooling indicating possible retropharyngeal abscess. 4
• Check for stridor, sitting-forward position, or respiratory distress suggesting epiglottitis (though extremely rare without fever). 4
• In adolescents/young adults with severe symptoms, consider Lemierre syndrome, though this typically presents with high fever. 4

If none of these red flags are present, proceed with symptomatic management.

Symptomatic Treatment

Analgesics are the cornerstone of management for sore throat without fever:

• Prescribe either ibuprofen or paracetamol (acetaminophen) for pain relief, as both are equally effective for acute sore throat symptoms. 1, 3, 2
• Corticosteroids are not recommended in this low-severity presentation (0-2 Centor criteria). 1, 3
• Zinc gluconate is not recommended for sore throat treatment. 1

What NOT to Do

Critical pitfalls to avoid:

• Do not prescribe antibiotics to prevent rheumatic fever or acute glomerulonephritis in low-risk patients like this one, as the absolute risk is negligible. 1, 3, 2
• Do not use antibiotics to prevent suppurative complications (quinsy, otitis media, sinusitis), as they do not reduce these outcomes in low-risk presentations. 1
• Do not order routine laboratory tests or biomarkers (C-reactive protein, procalcitonin), as they are not necessary for assessment of acute sore throat. 1
• Do not use rapid antigen tests (RATs) in patients with 0-2 Centor criteria, as testing is not indicated when clinical probability is low. 1

Expected Clinical Course

Educate the patient on natural history:

• Most sore throats are self-limiting within 7 days, even when bacterial, and resolve without antibiotics. 3, 5
• The majority of throat infections are viral and do not require antibiotic treatment. 6
• Advise the patient to return if symptoms worsen or persist beyond 7 days, as this warrants re-evaluation for alternative causes. 7, 8