• Admit immediately anyone who has:
• Stridor or respiratory difficulty.
• Respiratory distress, drooling, systemically very unwell, painful swallowing, muffled voice: suspect acute epiglottis. 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.

In depth

• 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.

In depth

• 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

• Reconsider the initial diagnosis.
• Consider 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 would refer 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).

In depth