Sore throat treatment
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Sore Throat (Pharyngitis): Treatment
Step 1: Identify the Cause First
Most sore throats are viral and require no antibiotics. The goal of evaluation is to identify the minority with Group A beta-hemolytic Streptococcus (GAS/GABHS) - the only common cause warranting antibiotic therapy. - Harrison's Principles of Internal Medicine 22E
The Modified Centor Score helps stratify risk:
| Criterion | Points |
|---|---|
| Tonsillar exudate | +1 |
| Tender anterior cervical lymphadenopathy | +1 |
| Fever (>38°C) | +1 |
| Absence of cough | +1 |
| Age 3-14 years | +1 |
| Age 45+ years | -1 |
- Score 0-1: No testing or antibiotics needed
- Score 2-3: Rapid antigen detection test (RADT) - treat if positive
- Score 4-5: Consider empiric antibiotics or confirm with RADT
- Rosen's Emergency Medicine; Goldman-Cecil Medicine
Viral Pharyngitis (the majority of cases)
Symptomatic relief only:
- Analgesics/antipyretics: Acetaminophen or NSAIDs (ibuprofen) - first-line for pain and fever
- Warm saline gargles, throat lozenges, adequate hydration
- No antibiotics - viral pharyngitis resolves spontaneously in 3-6 days without treatment
- Rosen's Emergency Medicine
Bacterial Pharyngitis (GAS Confirmed or High Probability)
First-Line Antibiotics
| Drug | Dose | Duration |
|---|---|---|
| Amoxicillin | 500 mg TID or 1g once daily (adults) | 10 days |
| Penicillin V | 500 mg BID-TID (adults) | 10 days |
Penicillin and amoxicillin are preferred for their narrow spectrum and low cost. GAS has never developed penicillin resistance. - Symptom to Diagnosis, 4th Ed.
Penicillin-Allergic Patients
- First-generation cephalosporins (cephalexin) - if non-anaphylactic allergy
- Clindamycin 300 mg TID x 10 days
- Clarithromycin or Azithromycin (note: up to 10% macrolide resistance in GAS)
- Symptom to Diagnosis, 4th Ed.
Goals of Antibiotic Treatment
- Reduce symptom severity and duration
- Prevent spread to contacts
- Prevent suppurative complications (peritonsillar abscess, otitis media)
- Prevent acute rheumatic fever (antibiotics reduce this risk by ~73%)
- Note: Antibiotics do not prevent post-streptococcal glomerulonephritis
- Goldman-Cecil Medicine; Harrison's 22E
Adjunctive: Corticosteroids
A single dose of dexamethasone 10 mg (adults) is safe and reduces symptom severity and duration in streptococcal pharyngitis, given alongside antibiotics. - Rosen's Emergency Medicine
Special Situations
| Situation | Management |
|---|---|
| Peritonsillar abscess | Needle aspiration or incision & drainage + antibiotics (penicillin or clindamycin); ultrasound-guided if available |
| Infectious mononucleosis (EBV) | Supportive only; avoid amoxicillin/ampicillin (causes rash); avoid contact sports (splenomegaly risk) |
| Gonorrheal pharyngitis | Ceftriaxone 500 mg IM single dose |
| Recurrent GAS pharyngitis | Clindamycin or amoxicillin-clavulanate (better beta-lactamase coverage) |
| Tonsillectomy | Only indicated for 4+ severe episodes per year |
| Diphtheritic pharyngitis | Diphtheria antitoxin + penicillin or erythromycin (notifiable disease) |
- Harrison's 22E; Symptom to Diagnosis 4th Ed.
Red Flags - Seek Urgent Evaluation
- Drooling, stridor, or muffled ("hot potato") voice - possible epiglottitis or deep space infection
- Trismus (difficulty opening mouth) - possible peritonsillar/parapharyngeal abscess
- Unilateral tonsillar swelling with uvular deviation - peritonsillar abscess
- Neck stiffness or torticollis - retropharyngeal abscess
- Symptoms lasting >2 weeks with weight loss, hoarseness - consider malignancy
- Rosen's Emergency Medicine; Goldman-Cecil Medicine
Key Points Summary
- Viral causes = majority - symptomatic treatment only; no antibiotics
- GAS = only bacterial cause requiring antibiotics - confirm with RADT before treating in most adults
- Penicillin/amoxicillin remain first-line for GAS (10 days)
- Dexamethasone (single dose) is a useful adjunct for symptom relief
- Failure to improve in 48 hours on appropriate antibiotics warrants re-evaluation
- Subacute/chronic pharyngitis should raise suspicion for abscess, HIV, or malignancy
Sources: Harrison's Principles of Internal Medicine 22E; Rosen's Emergency Medicine; Goldman-Cecil Medicine International Ed.; Symptom to Diagnosis 4th Ed.
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