Sore throat is one of the most common presenting symptoms in the general practice setting.
The most common cause of sore throat is viral infection. Commonly implicated viruses include rhinovirus, coronavirus, adenovirus, influenza and parainfluenza viruses. The most common bacterial organism responsible for sore throat is Group A beta-haemolytic streptococcus (GABHS). GABHS is responsible for approximately 20-40% of cases in children and around 10% in adults.
For many years inappropriate antibiotic prescribing for sore throats has been a widespread problem, and in January 2018 NICE released guidance that is designed to help clinicians make evidence-based decisions with regards to the appropriate treatment of sore throats.
Two scoring systems are recommended by NICE to assist in the assessment of sore throat:
- The Centor Clinical Prediction Score
- The FeverPAIN Score
Arguably, the FeverPAIN score, which is the more modern of the two scoring systems, is the slightly more accurate of the two, but the use of either is considered acceptable at present by NICE.
The Centor Clinical Prediction Prediction Score
The Centor Clinical Prediction Score uses a set of criteria that were initially developed as a tool to identify the likelihood of group A beta haemolytic Streptococcus (GABHS) infection in adult patients complaining of a sore throat. The Centor score was developed in US Emergency Departments and was only tested in adults.
Patients are judged on the following criteria, with one point for each positive criterion:
- History of a fever (Temp >38°C)
- Exudate or swelling on tonsils
- Tender or swollen anterior cervical lymph nodes
- Absence of cough
The current NICE guidance recommends that the score can be used to guide management as follows:
- Score 0 to 2 = 3-17% isolation of streptococcus, antibiotics not recommended
- Score 3 to 4 = 32-56% isolation of streptococcus, consider immediate treatment with empirical antibiotics or ‘backup prescription.’
The FeverPAIN Score
The Fever PAIN score was derived from a cohort study including 1760 adults and children aged 3 and over. The score was tested in a trial comparing three prescribing strategies; empirical delayed prescribing, use of the score to direct prescribing or combination of the score with use of a near patient test (NPT) for streptococcus. Using the score resulted in more rapid symptom resolution and reduced prescribing of antibiotics (both reduced by one third). The addition of the NPT did not confer any additional benefit.
The score consists of five items, each of which scores one point:
- Fever(Temp >38°C) in last 24 hours
- Attended rapidly in under 3 days
- Inflamed tonsils
- No cough or coryza
The recommendations based on the score are as follows:
- Score 0-1 = 13-18% isolation of streptococcus, antibiotics not recommended
- Score 2-3 = 34-40% isolation of streptococcus, consider delayed prescribing of antibiotics (3-5 day ‘backup prescription’)
- Score 4-5 = 62-65% isolation of streptococcus, use immediate antibiotic if severe, or 48-hour short ‘backup prescription.’
Treatment of sore throat
Patients should be guided with regards to sensible self-care measures, including the following:
- Paracetamol and/or ibuprofen for pain and fever control
- Good fluid intake – sore throat can occasionally result in significantly reduced fluid intake and dehydration
- Medicated lozenges (e.g. benzocaine, flurbiprofen) may help with symptom control
There is no evidence to support the use of non-medicated lozenges, throat sprays or mouthwashes alone.
For adults in whom antibiotics are indicated (see above), the following is recommended:
- 1st line – phenoxymethylpenicillin 500 mg QDS or 1 g BD for 5-10 days
- 2nd line – clarithromycin 250-500 mg BD for 5 days or erythromycin 250-500 mg QDS or 500-1000 mg BD for 5 days
- For paediatric doses, please refer to the BNF
NICE recommend that antibiotics should not be withheld if the person has very severe symptoms and there is concern about their clinical condition. The threshold for prescribing antibiotics should be lower in people at risk of rheumatic fever (such as people with a previous history of rheumatic fever and those living in South Africa, Australian indigenous communities, Maori communities of New Zealand, the Philippines, and many developing countries), and vulnerable groups of people who are being managed in primary care, (such as infants, very old people, and those who are immunosuppressed or immunocompromised).
It should be borne in mind that studies have shown that use of antibiotics for streptococcal sore throat decrease symptom duration by less than 1 day.
Routine follow-up is not required, but NICE recommend that patients should be advised to seek follow-up if:
- Symptoms have not improved after 3 or 4 days of antibiotic therapy – so that alternative diagnoses can be considered.
- Pain does not improve after 3 days, and/or there is fever over 38.3°C – so that antibiotic treatment can be initiated (if not in place already) or alternative diagnoses can be considered.
- It becomes difficult to swallow saliva or liquids, if any difficulty in breathing develops, or if there is any one-sided neck or throat swelling – so that the need for hospital admission can be reassessed (the person should be advised to seek advice urgently in these scenarios).
Indications for admission and special circumstances
Acute epiglottitis is a life-threatening emergency, and anyone with suspected epiglottitis should have an emergency ‘999’ ambulance transfer arranged to a hospital where there is the capacity to carry out immediate intubation should the airway close.
For other patients with acute sore throat, hospital admission should be arranged, using clinical judgement to determine urgency, for patients with:
- Breathing difficulty.
- Clinical dehydration.
- Peri-tonsillar abscess or cellulitis, parapharyngeal abscess, retropharyngeal abscess, or Lemierre syndrome (as there is a risk of airway compromise or rupture of the abscess).
- Signs of marked systemic illness or sepsis.
- A suspected rare cause such as Kawasaki disease, diphtheria, or yersinial pharyngitis.
For sore throat presenting in vulnerable patient groups (e.g. infants, elderly, immunosuppressed), pharyngitis/tonsillitis can run a more severe course, and clinical judgement should be used to determine the need for hospital admission.
For patients taking a disease-modifying anti-rheumatic drug (DMARD), the need for admission should be considered. If it is not deemed clinically indicated to admit the patient, an urgent full blood count should be arranged and the patient contacted with the results. The DMARD should be withheld in the interim, antibiotics prescribed, and the patient’s management should be discussed with the hospital rheumatology service. Seek urgent specialist advice/referral if the person has a low white cell count or deteriorates.
Carbimazole can cause idiosyncratic neutropenia, and patients taking this drug should have an urgent full blood count arranged, the drug withheld in the interim and their care discussed with a specialist. Antibiotic prescription should be considered.
If the patient is on chemotherapy, has known or suspected leukaemia, asplenia, aplastic anaemia or HIV/AIDS, or is taking an immunosuppressive drug following a transplant, immediate specialist advice or referral should be sought and the full blood count should be checked urgently.
Corticosteroids for the treatment of sore throat
A recent systematic review in the BMJ looked at the role of corticosteroids in patients with sore throat.
The authors concluded that single low dose corticosteroids can provide pain relief in patients with sore throat, with no significant increase in serious adverse effects. Steroids somewhat reduced the severity and duration of pain by one day, but time off school or work was unchanged.
The authors state that the recommendation is weak and shared decision making is needed because corticosteroids did not help all patient-reported outcomes and patients’ preferences varied substantially.
Referral for tonsillectomy
NICE recommends that referral to an ENT specialist for consideration of tonsillectomy should take place for patients with severe recurrent tonsillitis and no other explanation for the recurrent symptoms. Severe recurrent tonsillitis is defined as:
- More than 7 episodes per year for one year,
- More than 5 episodes per year for 2 years, or;
- More than 3 episodes per year for 3 years.
Thank you to the joint editorial team of MRCGP Exam Prep for this article.