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 greyish white membrane.
Yersinial pharyngitis: fever, prominent cervical lymphadenopathy, abdominal pain with or without diarrhoea.
When should I refer or seek advice?
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.
Who should I refer for consideration of tonsillectomy?
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 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 had five or more episodes per year of sore throat due to tonsillitis. The episodes should have been disabling and have prevented normal functioning.
When should I investigate?
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 Referral.
If infectious mononucleosis (glandular fever) is suspected and the person wishes to be tested:
In immunocompetent people over 12 years of age, the following tests may be done:
Full blood count, differential white cell count and blood film.
Heterophile antibodies (Monospot): false negative results are less likely after the second week of the illness.
Liver function tests.
In children under 12 years of age, and in people who are immunocompromised at any age, viral serology for the Epstein-Barr virus is preferred.
What advice should I give?
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.
If they are taking a disease-modifying anti-rheumatic drug (DMARD), or carbimazole tell them to stop this while waiting for 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.
When should I prescribe an antibiotic for sore throat?
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.
For people with sore throat where it is felt safe not to prescribe antibiotics immediately:
Use of delayed antibiotic prescriptions may be considered. Delayed prescription may help to reduce re-attendance.
However, there is no evidence to indicate that it is different to 'no antibiotics' in terms of symptom control, patient satisfaction and disease complications.
Prescribe an antibiotic for:
Those with features of marked systemic upset.
Those at increased risk of complications. 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 valvular heart disease.
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.
Which antibiotic should I prescribe for sore throat?
Prescribe phenoxymethylpenicillin (or erythromycin if the person is allergic to penicillin) for 10 days.
Avoid prescribing broad-spectrum penicillins (such as amoxicillin and ampicillin) for the blind treatment of sore throat.l summary: Management of persistent sore throat
How should I manage someone with persistent sore throat?
Reconsider the initial diagnosis.
Consider alternative diagnosis or further investigation if the individual has not responded to a course of antibiotics.
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).
1st line antibiotic: penicillin V for 10 daysLicensed use: yes
Patient Information: Continue to take painkillers if needed
Penicillin V s/f solution: 62.5mg four times a day
Age from 1 month to 11 months
Phenoxymethylpenicillin 125mg/5ml oral solution sugar free. Take 2.5ml four times a day for 10 days. Supply 100 ml.
Penicillin V s/f solution: 125mg four times a day
Age from 1 year to 5 years 11 months
Phenoxymethylpenicillin 125mg/5ml oral solution sugar free. Take one 5ml spoonful four times a day for 10 days. Supply 200 ml.
Penicillin V s/f solution: 250mg four times a day
Age from 6 years to 11 years 11 months
Phenoxymethylpenicillin 250mg/5ml oral solution sugar free. Take one 5ml spoonful four times a day for 10 days. Supply 200 ml.