Sore throat

Clinical Notes : ENT

122. Sore throat

Sore Throat

All people with sore throat

Algorithm for the management of sore throat

People who are unlikely to benefit from an antibiotic

People who may be more likely to benefit from an antibiotic

People who are most likely to benefit from an antibiotic

When to refer

Choice of antibiotic >18 yrs old

Choice of antibiotic <18 yrs old

All people with acute sore throat

Be aware that:
- acute sore throat (including pharyngitis and tonsillitis) is self‑limiting and often triggered by a viral infection of the upper respiratory tract
- symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus)
Assess and manage children under 5 who present with fever as outlined in the NICE guideline on fever in under 5s
Use FeverPAIN or Centor criteria to identify people who are more likely to benefit from an antibiotic and manage in line with recommendations below
Give advice about:
- the usual course of acute sore throat (can last around 1 week)
- managing symptoms, including pain, fever and dehydration, with self-care (see the recommendations on self-care)
Reassess at any time if symptoms worsen rapidly or significantly, taking account of:
- alternative diagnoses such as scarlet fever or glandular fever
- any symptoms or signs suggesting a more serious illness or condition
- previous antibiotic use, which may lead to resistant organisms

Go To : FeverPAIN score

Go To : Centor Score

Go To : Fever in Under 5s (124)

Algorithm for the management of sore throat

People who are unlikely to benefit from an antibiotic (FeverPAIN score of 0 or 1, or Centor score of 0, 1 or 2):

Do not offer an antibiotic prescription
As well as the general advice mentioned above, give advice about:
- an antibiotic not being needed
- seeking medical help if symptoms worsen rapidly or significantly, do not start to improve after 1 week, or the person becomes systemically very unwell

Go To : Prescribing Antibiotics (96)

People who may be more likely to benefit from an antibiotic (FeverPAIN score of 2 or 3)

Consider no antibiotic prescription with advice or a back-up antibiotic prescription, taking account of:
- evidence that antibiotics make little difference to how long symptoms last (on average, they shorten symptoms by about 16 hours)
- evidence that most people feel better after 1 week, with or without antibiotics
- the unlikely event of complications if antibiotics are withheld
- possible adverse effects, particularly diarrhoea and nausea
When a back-up antibiotic prescription is given, as well as the general advice in recommendation , give advice about:
- an antibiotic not being needed immediately
- using the back-up prescription if symptoms do not start to improve within 3 to 5 days or if they worsen rapidly or significantly at any time
- seeking medical help if symptoms worsen rapidly or significantly or the person becomes systemically very unwell

People who are most likely to benefit from an antibiotic (FeverPAIN score of 4 or 5, or Centor score of 3 or 4)

Consider an immediate antibiotic prescription (see recommendation for choice of antibiotic), or a back-up antibiotic prescription with advice (see recommendation ), taking account of:
- the unlikely event of complications if antibiotics are withheld
- possible adverse effects, particularly diarrhoea and nausea
When an immediate antibiotic prescription is given, as well as the general advice in recommendation , give advice about seeking medical help if symptoms worsen rapidly or significantly or the person becomes systemically very unwell

People who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high-risk of complications

Offer an immediate antibiotic prescription (see recommendation for choice of antibiotic) with advice or further appropriate investigation and management
Refer people to hospital if they have acute sore throat associated with any of the following:
- a severe systemic infection (see the NICE guideline on sepsis)
- severe suppurative complications (such as quinsy [peri-tonsillar abscess] or cellulitis, parapharyngeal abscess or retropharyngeal abscess or Lemierre syndrome)

Treating Your Infection

Patient Information leaflet to be used with patients who are experiencing self limiting URTIs

Adapted for use in ROI

From : Treat Antibiotics Responsibly, Guidance, Education, Tools (TARGET)

Royal College of General Practitioners (RCGP UK)

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Choice of antibiotic

When prescribing an antibiotic for acute sore throat:
- follow table 1 for adults aged 18 years and over
- follow table 2 for children and young people under 18 years

Sore throat : Antibiotics for adults aged 18 years and over

Sore throat : Antibiotics for children and young people under 18 years

Summary tables: infections in primary care

Management and treatment of common infections:

guidance for consultation and adaptation

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FeverPAIN criteria

Fever (during previous 24 hours)
Purulence (pus on tonsils)
Attend rapidly (within 3 days after onset of symptoms)
Severely Inflamed tonsils
No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5).

Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause.

A score of 0 or 1 is thought to be associated with a 13 to 18% likelihood of isolating streptococcus.

A score of 2 or 3 is thought to be associated with a 34 to 40% likelihood of isolating streptococcus.

A score of 4 or 5 is thought to be associated with a 62 to 65% likelihood of isolating streptococcus.

Centor criteria

Tonsillar exudate
Tender anterior cervical lymphadenopathy or lymphadenitis
History of fever (over 38°C)
Absence of cough

Each of the Centor criteria score 1 point (maximum score of 4).

A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus.

A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus

NICE Guideline NG84.

Sore throat (acute): antimicrobial prescribing.

January 2018

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NICE Guideline NG15

Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use

August 2015

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Shulman ST, Bisno AL, Clegg HW, et al.

Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.

Clin Infect Dis. 2012 Nov 15;55(10):e86-102.

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Management and treatment of common infections

Public Health England (PHE)

October 2017

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Spinks A, Glasziou PP, Del Mar CB.

Antibiotics for sore throat.

Cochrane Database Syst Rev. 2013 Nov 5;(11)

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de la Poza Abad M, Mas Dalmau G, Moreno Bakedano M, et al

Delayed Antibiotic Prescription (DAP) Group. Prescription strategies in acute uncomplicated respiratory infections: a randomized clinical trial.