• 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.

In depth

• 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.

In depth

• 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.
• 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.

In depth

• 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.

In depth