The information below is based on NICE NG84 Sore throat (acute): antimicrobial prescribing (January 2018). 

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). On average, antibiotics shorten the duration of symptoms by about 16 hours over 7 days, and the number of people improving with antibiotics is similar to the number experiencing adverse effects, such as diarrhoea.

For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2021).

Self-care advice:

• Consider paracetamol or ibuprofen for pain or fever
• Drink adequate fluids
• Adult patients may wish to try medicated lozenges with local anaesthetic/ NSAID/ antiseptic, but these may only reduce pain in small amount

The following are not recommended due to a lack of evidence: non-medicated lozenges, mouthwashes, or local anaesthetic mouth spray without antiseptic.

The poor sensitivity and specificity of the previous sore throat grading criteria (CENTOR) have led to these being replaced with the FeverPAIN criteria.

FeverPAIN criteria are used to identify patients most likely to benefit from antibiotics. Higher scores suggest more severe symptoms and likely bacterial strep cause. (1 point for each, maximum score of 5):

• Fever - Fever in the preceding 24 hours (measured or subjective)
• P - Purulence on the tonsillar bed
• A - Attend (self-refer) promptly i.e. within three days of symptom onset
• I – Severely inflamed tonsils
• N - No cough or coryza (inflammation of mucus membranes in the nose)

Scores

• 0-1 – Do not offer an antibiotic
• 2-3 – (Likelihood of streptococcal disease <40%, review at three days or use delayed prescription) Consider no antibiotic or a delayed antibiotic prescription
• 4-5 – (Likelihood of streptococcal disease >60%) Consider an immediate antibiotic or a delayed antibiotic prescription

Consider a 5-10 day prescription (delayed for 7 days) for patients presenting with symptoms which do not start to improve within the next 3 to 5 days or if they worsen rapidly or significantly at any time.

Reassess at any time if; symptoms worsen rapidly or significantly, or patient becomes very unwell.

In all cases offer self-care advice, no scoring system can ever be completely accurate, consider safety net precautions.

Invasive Group A Streptococcal infections and other bacteria have increased in incidence and need to be assessed rapidly in hospital. Maintain a high index of suspicion in patients with a high fever, severe muscle aches, confusion, unexplained D&V, local muscle tenderness, or severe pain out of proportion to external signs, hypotension, and a flat red rash over large area of the body, conjunctival suffusion.

Consider antibiotic treatment if confirmed Group A streptococcus infection in a household member and patient presents with symptoms suggestive of Group A streptococcal infection, including acute sore throat.

Chronic carriage of Group A streptococcus: These are apparent bacteriological treatment failures without illness or immunological response. They have a low risk of spread and a low risk of suppurative and non-suppurative complications. Antibiotics are not required.

The usefulness of throat swabs is limited by:

• Their low sensitivity and specificity, they do not distinguish between carriage and infection with haemolytic streptococci
• It takes time to obtain results (48-72 hours)

Immediate prescription of antibiotics is recommended in patients who:

• Are systemically very unwell
• Show signs and symptoms suggestive of serious illness
• Are at risk of developing complications because of pre-existing co-morbidity, including significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and young children born prematurely
• Are older than 65 years with acute cough and two or more of the following criteria; or older than 80 years with acute cough and one or more of the following criteria:
  • Hospitalisation in previous year
  • Type 1 or type 2 diabetes
  • History of congestive heart failure
  • Current use of oral glucocorticoids

Please see local referral guidelines if recurrent acute tonsillitis/ tonsillectomy.

• Western locality
• South Devon & Torbay

Where antibiotics are indicated

Phenoxymethylpenicillin

(including pregnancy)

• Adults and children over 12 years of age:
  • 500mg four times a day for 5-10 days or
  • 1000mg twice daily for 5-10 days
• Child 1 month to 11 years (doses given for 5-10 days)
  • 1 month to 11 months: 62.5mg four times a day or 125mg twice daily
  • 1 to 5 years: 125mg four times a day or 250mg twice daily
  • 6 to 11 years: 250mg four times a day or 500mg twice daily

Penicillin allergy

Clarithromycin

• Adults and children over 12 years of age:
  • 250mg to 500mg twice daily for 5 days
• Children 1 month to 11 years (doses given twice daily for 5 days):
  • Body-weight under 8 kg: 7.5mg/kg
  • Body-weight 8–11 kg: 62.5mg
  • Body-weight 12–19 kg: 125mg
  • Body-weight 20–29 kg: 187.5mg
  • Body-weight 30–40 kg: 250mg

Penicillin allergy in pregnancy

Erythromycin

• 250mg to 500mg four times a day for 5 days

See 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides