• Admit immediately anyone who has stridor, breathing difficulty, or dehydration. Do not examine the throat of anyone with suspected epiglottitis.
• Identify people who:
• Need simple self-care advice only.
• Are at risk of immunosuppression.
• Might benefit from an antibiotic.
• Might benefit from tonsillectomy.
• Refer urgently anyone who has suspected cancer of the throat.

• Admit immediately anyone who has:
• Stridor or respiratory difficulty.
• Respiratory distress, drooling, systemically very unwell, painful swallowing, muffled voice: suspect acute epiglottitis. Do not examine the throat of anyone who has suspected epiglottitis.
• Upper airway obstruction.
• Dehydration or reluctance to take any fluids.
• Severe suppurative complications (e.g. 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 being markedly systemically unwell and is at risk of immunosuppression.
• Suspected Kawasaki disease.
• Diphtheria: characteristic tonsillar or pharyngeal membrane.
• Signs of being profoundly unwell and the cause is unknown or a rare cause is suspected, for example:
• Stevens–Johnson syndrome: high fever, arthralgia, myalgia, extensive bullae in the mouth followed by erosion and a grey–white membrane.
• Yersinial pharyngitis: fever, prominent cervical lymphadenopathy, abdominal pain with or without diarrhoea.

• The basis for these recommendations is expert advice from national guidance [SIGN, 1999; NICE, 2001], standard textbooks [Breathnach, 2004; Bisno, 2005] and advice from our expert reviewers.

• If the person may be immunosuppressed:
• If taking a disease-modifying anti-rheumatic drug (DMARD) and immediate admission is not appropriate then:
• Take blood for a full blood count (FBC). Arrange to contact them later with the result.
• Withhold the DMARD whilst awaiting the result and until discussed with the hospital rheumatology service (or follow local protocols).
• Seek urgent specialist advice/referral if the person has a low white cell count or deteriorates.
• Provide symptomatic relief.
• Consider prescribing an antibiotic taking into account potential interactions with DMARDs.
• If the person is taking carbimazole (which can cause idiosyncratic neutropenia) take an urgent FBC and withhold the drug until the result is available. Seek specialist advice. Consider prescribing an antibiotic.
• If the person is on chemotherapy, has known or suspected leukaemia, asplenia, aplastic anaemia or HIV/AIDS, or is taking an immunosuppressive drug following a transplant:
• Seek immediate specialist advice or referral.
• Meanwhile check the FBC urgently.
• Refer or seek urgent specialist advice for anyone who has severe oral mucositis. For further information, see the CKS topic on Palliative cancer care - oral.
• Identify people who may need non urgent referral for consideration of tonsillectomy:
• Confirm the diagnosis of recurrent tonsillitis by history and examination, if possible differentiating it from pharyngitis. In practice this may be difficult to do because people do not always consult when they have sore throat and there may be uncertainty about whether previous sore throats were due to acute tonsillitis or pharyngitis.
• Note whether the frequency of episodes is increasing or decreasing.
• In most children only consider referral for tonsillectomy if all of the following criteria are met:
• The child has five or more episodes of acute sore throat per year, documented by the parent or clinician.
• Symptoms have been occurring for at least a year.
• The episodes of sore throat have been severe enough to disrupt the child's normal behaviour or day to day functioning.
• Refer if the child has guttate psoriasis which is exacerbated by recurrent tonsillitis.
• Refer if the child has a history of sleep apnoea, daytime drowsiness, and failure to thrive.
• Refer adults if they have had five or more episodes per year of sore throat due to tonsillitis. The episodes should have been disabling and have prevented normal functioning.

• The definition of recurrence is arbitrary and for the purposes of deciding who should be referred is defined as five or more episodes in the previous 12 months. The diagnosis of recurrence does not depend on the underlying cause (viral, bacterial) or on the severity of the sore throat [NICE, 2001].
• Consider keeping a sore throat diary in order to establish any pattern of recurrence and the impact on the child's day to day activities [NICE, 2001].
• Discuss the advantages and disadvantages of tonsillectomy including the natural history of resolution [SIGN, 1999].

• The basis for these recommendations is expert advice from standard textbooks [Jones, 1998; Franco and Har-El, 1999; Dhillon and East, 2006].
• The National Institute for Health and Clinical Excellence (NICE) advises immediate referral for anyone with suspected leukaemia [NICE, 2005].
• The basis for these recommendations regarding recurrent episodes of acute sore throat is expert advice from national guidance:
• The recommendations for referral of children for tonsillectomy are based on expert opinion from the National Institute for Health and Clinical Excellence and apply to people aged up to 15 years with recurrent acute sore throat [NICE, 2001].
• The recommendations for referral of adults for tonsillectomy are based on expert opinion from the Scottish Intercollegiate Guidelines Network that apply to both children and adults as reasonable indications for consideration of tonsillectomy based on the current level of knowledge, clinical observation in the field and the results of clinical audit [SIGN, 1999].
• Evidence for the benefits of tonsillectomy is poor. In children surgery may be beneficial in selected cases. In adults, limited evidence suggests that tonsillectomy may benefit people with recurrent infection.
• The recommendations regarding people who are immunosuppressed on based on national guidelines [British Society for Rheumatology, 2000] and the opinion of our expert reviewers.

• 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.

• Prescribe phenoxymethylpenicillin for 10 days.
• If the person is allergic to penicillin, prescribe erythromycin or clarithromycin for 5 days.
• Avoid prescribing broad-spectrum penicillins (such as amoxicillin and ampicillin) for the blind treatment of a sore throat.

These recommendations are based on those issued by the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 1999], the Royal College of Paediatrics and Child Health (RCPCH) [RCPCH, 2000], and the Health Protection Agency [HPA and Association of Medical Microbiologists, 2010].

• Phenoxymethylpenicillin remains the treatment of choice compared with other antibiotic options, based on the combination of its proven efficacy, narrow spectrum, safety, and low cost [SIGN, 1999; RCPCH, 2000; Bisno, 2001; MeReC, 2006; HPA and Association of Medical Microbiologists, 2010].
• A 10–day treatment course with phenoxymethylpenicillin is generally recommended [SIGN, 1999; RCPCH, 2000; MeReC, 2006; HPA and Association of Medical Microbiologists, 2010]. This is to ensure the maximal rate of eradication of the infection [Bisno, 2001]:
• In people with group A streptococcal pharyngitis, one randomized trial found that those treated with phenoxymethylpenicillin for 7 days had a significantly greater treatment failure rate (30/96, 31%) compared with those receiving 10 days of phenoxymethylpenicillin (17/95, 18%). Compliance rates were 66–81% of patients [Schwartz et al, 1981].
• Erythromycin and clarithromycin should be reserved for use in people with penicillin allergy. Macrolides have a broader spectrum of activity than phenoxymethylpenicillin and are thus more likely to drive the emergence of bacterial resistance, increase the risk of developing Clostridium difficile, and are associated with more adverse effects [HPA and Association of Medical Microbiologists, 2010].
• A 5–day treatment course of erythromycin or clarithromycin is recommended [HPA and Association of Medical Microbiologists, 2010].
• A systematic review of short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children found that short courses of broad-spectrum antibiotics were as effective as 10–day courses of penicillin for sore throat symptom treatment [Altamimi et al, 2009].
• Amoxicillin and glandular fever:
• Amoxicillin and other broad-spectrum penicillins should not be used for the blind treatment of sore throat. Maculopapular rashes occur commonly with ampicillin and amoxicillin but are not usually related to true penicillin allergy. They almost always occur in people with infectious mononucleosis [ABPI Medicines Compendium, 2005; BNF 54, 2007].

• Throat swabs or rapid antigen tests should not be carried out routinely in the investigation of acute sore throat.
• If the person is at risk of immunosuppression, see the section on Referral.
• Suspect glandular fever in a person with a sore throat that fails to improve, or becomes worse, after several days. For more information see the section on Investigations in the CKS topic on Glandular fever.

• Throat swabs:
• Throat swabs cannot differentiate between infection and carriage, they have poor sensitivity, results take up to 48 hours to be reported, and the analysis is relatively expensive [Little and Williamson, 1996; MeReC, 1999; SIGN, 1999].
• The results of throat swabs vary according to technique, culture site, and culture conditions [Cooper et al, 2001].
• Group A beta-haemolytic streptococcus (GABHS) can be isolated from up to 30% of people presenting with sore throat [Bisno, 2005]. However, figures for asymptomatic carriage range from 6% to 40% [Little and Williamson, 1996]. Carriers have low infectivity and are not at risk of developing complications.
• Swabs may be useful in high-risk groups, to guide the choice of treatment if treatment failure occurs (see the section on Choice of antibiotic).
• Rapid antigen tests:
• Rapid antigen tests detect the presence of group A streptococcal antigen on a throat swab and produce results within a few minutes. However, they have poor sensitivity and make little impact on prescribing decisions [SIGN, 1999; Cooper et al, 2001].

• Reassure the individual that a sore throat is generally self limiting, with most immunocompetent people recovering after 7 days with or without antibiotic treatment.
• Advise the person to see a healthcare professional if they do not improve. Explain that they should seek urgent medical attention if they develop any difficulty breathing, stridor, drooling, a muffled voice, severe pain, dysphagia, or if they are not able to swallow adequate fluids or become systemically very unwell.
• Advise regular use of paracetamol or ibuprofen to relieve pain and fever.
• Provide advice regarding food and drink to avoid exacerbating pain (e.g. avoid hot drinks).
• Suggest the use of simple mouthwashes (e.g. warm salty water) at frequent intervals until the discomfort and swelling subside.
• Discuss the role of antibiotics (see Prescribing an antibiotic).
• If the person is immunosuppressed:
• If they are taking a disease-modifying anti-rheumatic drug (DMARD) or carbimazole, tell them to stop this while waiting for the result of a full blood count (FBC). Arrange to contact them later with the result and explain that you will seek specialist advice.
• Stress that they should seek immediate medical advice if they become systemically unwell.
• Explain to all other people who are immunosuppressed that you will seek urgent specialist advice. This includes people who:
• Have leukaemia, aplastic anaemia, asplenia or HIV/AIDS.
• Are on chemotherapy or who are taking an immunosuppressive drug following a transplant. Advise them not to stop their medication unless after your discussion with the specialist they are advised to do so.

• Other self care advice:
• Adults or older children may find sucking throat lozenges, hard boiled sweets, ice, or flavoured frozen desserts (such as ice lollies) to provide additional symptomatic relief.
• Encourage adequate fluid intake to avoid dehydration if fever is present.

• These recommendations are based on pragmatic advice and guidance issued by Scottish Intercollegiate Guidelines Network (SIGN), the National Clinical Systems Improvement, National Institute for Health and Clinical Excellence (NICE) and the Royal College of Paediatrics and Child Health (RCPCH) [SIGN, 1999; RCPCH, 2000; ICSI, 2007; NICE, 2007; NICE, 2008a].
• Most throat infections are caused by viruses and are self limiting. Many do not require antibiotic therapy [DH and SMAC, 1998; MeReC, 2006; BNF 54, 2007]. There is evidence to indicate that one of the principle reasons for people with sore throat to visit their doctors is for reassurance.
• Systemic analgesics:
• Oral analgesics are recommended for the symptomatic relief of sore throat [MeReC, 1999; SIGN, 1999; RCPCH, 2000; MeReC, 2006]. A systematic review found systemic analgesics (paracetamol, nonsteroidal anti-inflammatory drugs, aspirin) to be helpful in relieving symptoms of sore throat [Thomas et al, 2000]. There is some evidence to indicate that, for short-term use (7 days), paracetamol and ibuprofen are equally well tolerated and both are better tolerated than aspirin.
• Local analgesics:
• Local analgesics are licensed for the symptomatic relief of sore throat. However, the evidence for flurbiprofen lozenges and benzydamine gargle are poor. CKS found no good evidence to support their use.

• Reconsider the initial diagnosis.
• Consider an alternative diagnosis or further investigation if the individual has not responded to a course of antibiotics.
• Consider cancer if the sore throat is persistent, especially if there is a neck mass.
• Refer urgently anyone with:
• An unexplained persistent sore or painful throat. 'Persistent' refers to a time frame of 3 to 4 weeks.
• Red, or red and white patches, or ulceration or swelling of the oral/pharyngeal mucosa for more than 3 weeks.
• Pain on swallowing or dysphagia for more than 3 weeks.
• Suspect infectious mononucleosis if sore throat and lethargy persist into the second week, especially if the person is 15–25 years of age. Request a full blood count, differential white cell count and blood film to look for mononuclear leucocytosis, and a Monospot test to look for heterophile antibodies if the person wishes to be tested.
• Consider non-infectious causes of sore throat (for example, gastro-oesophageal reflux disease, chronic irritation from cigarette smoke, alcohol, or hayfever).

• Suspected cancer [Jones, 1998; Manni, 1998; Franco and Har-El, 1999; Dhillon and East, 2006]:
• Hypopharyngeal cancer (includes the pyriform sinus, lateral pharyngeal wall, posterior pharyngeal wall, and post cricoid region): this may present with a unilateral, well-localized, persistent sore throat; a vague discomfort on swallowing; and referred pain to the ear; or as a neck mass due to cervical node metastases. Dysphagia is a late symptom. There may be weight loss. It is not directly visible on examination.
• Oropharyngeal cancer (includes the tonsils and faucial pillars, base of the tongue, soft palate, and uvula): there may be sore throat, otalgia, and progressive dysphagia; trismus or a foreign body; or mass sensation in the throat. Many people complain of the sensation of a 'lump at the back of the throat'. An ulcer is usually visible on examination. It often presents with a neck mass due to metastases to the cervical nodes.

• The basis for these recommendations is expert advice from national guidance [National Collaborating Centre for Primary Care, 2005] and standard textbooks [Jones, 1998; Pagana and Pagana, 2002; Johannsen et al, 2005].
• The National Institute for Health and Clinical Excellence (NICE) guidance recommends referring urgently everyone with an unexplained, persistent sore or painful throat [NICE, 2005]. Our expert reviewers suggested a time frame of 3 to 4 weeks for 'persistent' and also recommended a time frame of 3 weeks for people with red, or red and white patches, or ulceration or swelling of the oral/pharyngeal mucosa or pain on swallowing or dysphagia.