Sore Throat
NICE guideline [NG84] Sore throat (acute): antimicrobial prescribing. Published: Jan 2018.
Indications of referral for tonsillectomy in recurrent tonsillitis has been added.
Date: 21/11/25
Background Information
Definition
Sore throat is a clinical presentation caused by pharyngitis and/or tonsillitis.
Aetiology
Most common cause: viral infection
Classification of pharyngitis / tonsilitis causes:
| Category | Organisms |
|---|---|
| Viral |
|
| Bacterial |
|
It is also important to be aware of non-infectious causes of sore throat:
- Post-nasal drip (excess mucus from the nose and sinuses drains down the pharynx, causing irritation)
- Allergic rhinitis
- Environmental irritants (e.g. smoke, air pollution)
- GORD
- Vocal strain
- Dry hair
Complications
Viral pharyngitis is often uncomplicated.
Complications mainly arise from streptococcal pharyngitis / tonsilitis, but are rare:
- Acute otitis media – most common
- Acute sinuitis
- Quinsy (peritonsillar abscess)
- Immune-mediated complications (rare in developed countries)
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Reactive arthritis
Pharyngitis / tonsillitis from Fusobacterium necrophorum can very rarely lead to Lemierre disease (triad of recent tonsillitis + septic thrombophlebitis of the internal jugular vein + septic emboli)
Scarlet fever is NOT a complication of streptococcal pharyngitis. It is a direct clinical syndrome due to an erythrogenic (pyrogenic) toxin-producing Group A streptococcus. Pharyngitis is part of the clinical presentation of scarlet fever, along with additional toxin-mediated features (e.g. rash, skin desquamation, strawberry tongue).
Diagnosis
Assessment and Diagnosis
Sore throat is a clinical diagnosis
Perform a clinical examination to:
- Exclude signs of a more serious illness / condition (e.g. sepsis, acute epiglottitis, quinsy)
- Ensure the patient is clinically stable and not systemically unwell
- Exclude signs of lower respiratory tract infection (pneumonia or acute bronchitis)
- Calculate the Centor / FeverPAIN score to guide management (see below for more details)
A throat swab or Group A Streptococcus antigen test is not recommended in the context of sore throat.
Centor and FeverPAIN Score
| Score | Components | Interpretation |
|---|---|---|
| Centor |
|
|
| FeverPAIN |
|
|
Both Centor and FeverPAIN scores are used to determine the likelihood of streptococcus pharyngitis, to reduce unnecessary antibiotic prescription.
In conclusion, bacterial pharyngitis is more likely if:
- There is no cough
- There is no coryza (eg rhinorrhoea, congestion)
- High fever
- Presence of tonsillar exudate
- Tender anterior cervical lymphadenopathy
Management
If the patient has possible sepsis or severe complications → refer to the hospital
Approach for other patients:
- All patients should be offered self-care management
- Do not routinely give antibiotics, use the Centor or FeverPAIN score to guide antibiotic prescription (see below)
Self-Care Management
Advise the patient to:
- Drink adequate fluids
- Consider paracetamol / ibuprofen for pain or fever
- Patients may wish to try medicated lozenges (containing e.g., local anaesthetic, NSAID, antiseptic)
Antibiotic Therapy
Indications for Antibiotics
Offer immediate antibiotic prescription if any of the following:
- Systemically very unwell
- Features of a more serious illness / condition
- High risk of complications (e.g. diabetes, heart failure, chronic respiratory disease, history of rheumatic fever)
Otherwise, the Centor (more commonly used) or FeverPAIN score should be used to guide antibiotic prescription:
| Centor score | FeverPAIN | Recommended management |
|---|---|---|
| 0 / 1 | 0 / 1 / 2 | Do not offer antibiotics |
| n/a | 2 / 3 | Consider no antibiotics or back-up prescription |
| 3 / 4 | 4 / 5 | Consider antibiotics (immediate / back-up prescription) |
NICE has a high threshold for prescribing antibiotics because antibiotics make little difference in the duration or improvement of symptoms for most sore throats. Additionally, withholding antibiotics rarely leads to complications.
On the other hand, antibiotics can cause adverse effects, such as diarrhoea and nausea, and their use contributes to antibiotic resistance.
Choice of Antibiotics
1st line: phenoxymethylpenicillin (penicillin V)
- 500mg QDS or 1g BD
- For 5-10 days (5 days may be enough for symptomatic cure, but 10 days may increase the chance of microbiological cure)
2nd line (penicillin alternatives):
- Clarithromycin 250-500 mg BD for 5 days
- If pregnant: erythromycin 250-500mg QDS / 500-1000mg BD for 5 days
The choice of antibiotics in the paediatric population remains the same. The only difference is dose adjustment.
Recurrent Tonsillitis
Patients with recurrent tonsillitis may benefit from tonsillectomy.
Refer the following patients to ENT, for tonsillectomy consideration:
- Past 1 year, with 7 or more episodes of clinically significant tonsillitis
- Past 2 years, with 5 or more episodes in each year
- Past 3 years, with 3 or more episodes in each year
References