• Do not routinely prescribe antibiotics for acute sore throat.
• Antibiotics should not be prescribed to:
• Secure symptomatic relief.
• Prevent suppurative complications.
• Treat recurrent non-streptococcal sore throat.
• Prevent the development of rheumatic fever and acute glomerulonephritis.
• Consider a delayed antibiotic prescribing strategy for people with sore throat where it is felt safe not to prescribe antibiotics immediately.
• Reassure the person that antibiotics are not needed immediately as they will make little difference to symptoms, and may have adverse effects.
• Advise the person to use the delayed prescription if symptoms do not settle or get significantly worse.
• Advise the person about the need for review if symptoms get significantly worse despite using the delayed prescription.
• A delayed prescription can either be given to the person with instructions, or collected at a later date.
• Consider a 2 or 3-day delayed prescription or immediate antibiotics for people with a sore throat and a Centor score of 3 or 4 (presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough).
• Prescribe an antibiotic for:
• Those with features of marked systemic upset.
• Those at increase risk of serious complications.
• Those with valvular heart disease.
• Have a low threshold for prescribing an antibiotic in people:
• With an increased risk of severe infection (e.g. diabetes or immunocompromised).
• Who are at risk of immunosuppression (e.g. on disease-modifying anti-rheumatic drugs [DMARDs], carbimazole).
• With a history of rheumatic fever.
• People with peritonsillar abscess or peritonsillar cellulitis will receive antibiotics in secondary care: admit immediately.
• An antibiotic may be useful in:
• Preventing cross-infections with group A beta-haemolytic streptococcus (GABHS) in closed institutions such as barracks or boarding schools. However, it should not be used routinely to prevent cross-infection in the general community.
• Treating recurrent sore throat associated with GABHS.

Delayed antibiotic prescribing strategy:

• A delayed prescription strategy aims to reduce the usage of antibiotics while providing a safety net for people who genuinely need antibiotics. Usually the person should be advised to use the antibiotic prescription only if their condition has deteriorated within 3 days or not improved after 3 days. The strategy can be implemented in a number of ways including:
• People may be issued a script and advised not to redeem it unless it is required. If necessary, the prescription can be post-dated.
• People can be asked to re-attend the GP surgery reception after 3 days to collect the prescription (if required). If symptoms significantly deteriorate before this time, a telephone consultation can be considered.
• Always give advice and reassure the person as well as giving the prescription. Consider giving written advice (such as a patient information leaflet).

Centor criteria

• The Centor criteria was developed to predict bacterial infection (GABHS) in people with acute sore throat. The four Centor criteria are:
• Presence of tonsillar exudate.
• Presence of tender anterior cervical lymphadenopathy or lymphadenitis.
• History of fever.
• Absence of cough.
• The presence of three or four of these clinical signs (Centor score 3 or 4) suggests that the person may have GABHS (40–60% chance) and may benefit from antibiotics treatment.
• The absence of three or four of these signs suggests that the person is unlikely to have an infection (80% chance), and antibiotics treatment is unlikely to be necessary.

These recommendations are based on those issued by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2001; NICE, 2008a], the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 1999], the Royal College of Paediatrics and Child Health (RCPCH) [RCPCH, 2000], and the British National Formulary (BNF) [BNF 54, 2007].

Antibiotic effectiveness

• Antibiotics have little effect on the extent and duration of symptoms of sore throat in most people [NICE, 2001].
• Evidence from a Cochrane review found that the absolute benefits of antibiotic treatment on the duration of symptoms were modest — a reduction of illness of about one day at around day 3 [Del Mar et al, 2006].
• However, studies (included in the systematic review) that used three of four of the Centor criteria for bacterial infection to determine eligibility showed a little more benefit from antibiotics for both symptom resolution and prevention of complications.

Delayed prescribing strategy

• Recommendations for the delayed antibiotic prescribing strategy are based on the clinical guideline Respiratory Tract Infections — antibiotic prescribing. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care, published by the National Institute for Health and Clinical Evidence (NICE) [NICE, 2008a].
• NICE do not offer clear guidance on who should be offered delayed treatment, or how this strategy should be carried out in practice, but CKS believes that if sore throat symptoms do not settle or get significantly worse, this strategy should be considered.
• There is evidence from a Cochrane review that a delayed prescribing strategy reduced antibiotic use compared with immediate antibiotic prescribing for respiratory infections, but was no different to a 'no antibiotics' prescribing strategy regarding symptom control, patient satisfaction, or complication rates [Spurling et al, 2007].
• There is evidence from a UK study that delayed antibiotic prescribing helped to reduce re-attendance rates [Little et al, 1997a].

Antibiotic effect on complications

• There is evidence from large studies that the risk of complications of sore throat, with or without antibiotic treatment, are low for most people. Therefore, using antibiotics to prevent complications provides only a small benefit [Little et al, 2002; Petersen et al, 2007].

People at high risk of a serious complication

• There is evidence from studies in the UK that, in the general population, the risk of severe complications following an RTI is low [Little et al, 2002; Petersen et al, 2007].
• NICE recommend prescribing an antibiotic for people who are at high risk of serious complications because of pre-existing comorbidity [NICE, 2008b]. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely.
• It requires some clinical judgement to decide when the risk of severe complications is high enough to warrant prescribing antibiotics for people with diabetes, immunocompromise, immunosuppression, or history of rheumatic fever or valvular heat disease.
• For people with a history of rheumatic fever, the risk of complications depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to group A strep infections, the age of the patient, and the presence or absence of cardiac involvement [Gerber et al, 2009].
• For people with valvular heart disease, the risk of severe complications (infective endocarditis) is high so NICE recommend to investigate and treat promptly any episodes of infection in people at risk of infective endocarditis to reduce the risk of endocarditis developing [NICE, 2008b].

Disease-modifying anti-rheumatic drugs (DMARDs)

• The recommendation regarding the management of people on DMARDs is based on the opinions of our expert reviewers.