antibiotic treatment for sore throat based on FEVERpain or Centor criteria

Last edited 12/2022 and last reviewed 02/2023

Antibiotics are given more frequently than the clinical indications would suggest. Fewer patients will be treated with antibiotics as more practitioners reach a consensus. It may be valuable to consider the indications for antibiotics before prescribing.

Penicillin V is the antibiotic of choice.

Erythromycin may be used if allergic to penicillin.

Ampicillin is contraindicated as it may precipitate a diffuse maculopapular rash if the patient has glandular fever.

Summary of Public Health England (PHE) guidance regarding antibiotic treatment of sore throat (1)

• in general, avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours
• if Centor score 3 or 4: (Lymphadenopathy; No Cough; Fever; Tonsillar Exudate) - consider 2 or 3-day delayed or immediate antibiotics or rapid antigen test
• antibiotics to prevent Quinsy number needed to treat (NNT) >4000
• antibiotics to prevent Otitis media NNT 200
• 10d penicillin lower relapse vs 7d in RCT in <18yrs
  
  
• adult dose of antibiotics:
  • phenoxymethylpenicillin 500mg qds for 5-10/7 (1g BD as an alternative)
  • if penicillin allergic then clarithromycin 250-500mg bd for 5/7

NICE suggest to base use of antibiotics on the FEVERpain or Centor Criteria scores (2):

• Management of sore throat based on FeverPAIN criteria

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

  • an antibiotic prescription should not be offered
  • as well as the general advice (see notes below), give advice about:
    • an antibiotic not being required
    • seeking medical help if symptoms worsen rapidly or significantly, do not start to improve after 1 week, or the person becomes systemically very unwell.

  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 (delayed 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
  • updated guidance states (4)
    • given the current high prevalence of Group A streptococcus (GAS), and the increased likelihood of GAS as cause of sore throat in children, the current CPR sore has been adjusted, with a recommendation to prescribe antibiotics to children with a FeverPAIN score of 3 or more
      • continue to follow clinical judgement as usual
        
        

  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, or a back-up antibiotic prescription, 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 (see notes), give advice about seeking medical help if symptoms worsen rapidly or significantly or the person becomes systemically very unwell
  • updated guidance states (4)
    • given the current high prevalence of Group A streptococcus (GAS), and the increased likelihood of GAS as cause of sore throat in children, the current CPR sore has been adjusted, with a recommendation to prescribe antibiotics to children with a FeverPAIN score of 3 or more
      • continue to follow clinical judgement as usual
        
        

  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 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
    • severe suppurative complications (such as quinsy [peri-tonsillar abscess] or cellulitis, parapharyngeal abscess or retropharyngeal abscess or Lemierre syndrome)

  • antibiotics for adults aged 18 years and over (a,b,c)

    • first choice
    • Phenoxymethylpenicillin 500 mg four times a day or 1,000 mg twice a day for 5 to 10 days* (3)
      
      
    • alternative first choices for penicillin allergy or intolerance
    • clarithromycin 250 mg to 500 mg twice a day for 5 days
    • erythromycin 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days
    • a. see BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding
    • b. doses given are by mouth using immediate-release medicines, unless otherwise stated
    • c. erythromycin is the preferred antibiotic in women who are pregnant (3)
    • *5 days of phenoxymethylpenicillin may be enough for symptomatic cure; but a 10-day course may increase the chance of microbiological cure
      
      
  • when prescribing oral antibiotics for possible group A streptococcus (4)
    • phenoxymethylpenicillin remains first line due to its high effectiveness, no reported resistance, and narrow spectrum of activity. In the event of non-availability, amoxicillin, macrolides and cefalexin are alternative agents in decreasing preference
    • in non severe-penicillin allergy, macrolides are the option of choice, with cefalexin as an alternative
    • in severe penicillin allergy, macrolides remain the option of choice. Co-trimoxazole is an option in the event of macrolide non-availability and penicillin anaphylaxis. A severe penicillin allergy is when there is a history of allergy to penicillin with effects that are clearly likely to be allergic in nature such as anaphylaxis, respiratory distress, angioedema or urticaria
    • both cefalexin and co-trimoxazole are broad-spectrum agents that may promote the development of antimicrobial resistance. Resistance to macrolides and co-trimoxazole is currently 7% and 10% respectively
    • antibiotic treatment length for sore throat
      • for phenoxymethylpenicillin:
        • five days of phenoxymethylpenicillin may be enough for symptomatic cure, but a 10-day course may increase the chance of microbiological cure

Notes:

• General advice about sore throat management
  • the usual course of acute sore throat (can last around 1 week)
  • managing symptoms, including pain, fever and dehydration, with 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
• Back-up prescription
  • a back-up (delayed) prescription is one that is given in a way to delay the use of a medicine (usually an antibiotic), and with advice to only use it if symptoms worsen or don't improve within a specified time. The prescription may be given during the consultation (which may be a post-dated prescription) or left at an agreed location for collection at a later date
  • when a back-up antibiotic prescription is given, as well as the general advice, 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
      
      
• a systematic review concerning the use of antibiotics for sore throat in children and adults concluded (4)
  • "...antibiotics probably reduce the number of people experiencing sore throat, and reduce the likelihood of headache, and some sore throat complications. As the effect on symptoms can be small, clinicians must judge on an individual basis whether it is clinically justifiable to use antibiotics to produce this effect, and whether the underlying cause of the sore throat is likely to be of bacterial origin. Furthermore, the balance between modest symptom reduction and the potential hazards of antimicrobial resistance must be recognised. Few trials have attempted to measure symptom severity. If antibiotics reduce the severity as well as the duration of symptoms, their benefit will have been underestimated in this meta-analysis. Additionally, more trials are needed in low-income countries, in socio-economically deprived sections of high-income countries, as well as in children.."

Reference:

1. Public Health England (October 2014). Management of infection guidance for primary care for consultation and local adaptation
2. NICE (January 2018).Sore throat (acute): antimicrobial prescribing
3. Public Health England (June 2021). Managing common infections: guidance for primary care
4. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database of Systematic Reviews 2021, Issue 12. Art. No.: CD000023. DOI: 10.1002/14651858.CD000023.pub5
5. NHS England. Group A streptococcus communications to clinicians (December 2022).