indications for antibiotics

Last edited 12/2022 and last reviewed 12/2022

Antibiotics are indicated for sore throat when they will significantly alter the course of an illness caused by pathogenic bacteria. It is difficult to define a pathogen as asymptomatic carrier states are recognised.

Some indications for treatment include:

  • complications of streptococcal sore throats
  • possible streptococcal sore throat within 24 hours of onset of illness
  • diphtheria
  • gonorrhoea
  • sore throat in immunocompromised patients - blood dyscrasias and leukaemia can be associated with throat infections
  • syphilis

NICE suggest management of sore throat based on FeverPAIN criteria (1)

People who are unlikely to benefit from an antibiotic (FeverPAIN score of 0 or 1, or Centor score of 0, 1 or 2):

  • an antibiotic prescription should not be offered
  • as well as the general advice (see notes below), give advice about:
    • an antibiotic not being required
    • seeking medical help if symptoms worsen rapidly or significantly, do not start to improve after 1 week, or the person becomes systemically very unwell.

People who may be more likely to benefit from an antibiotic (FeverPAIN score of 2 or 3)

  • consider no antibiotic prescription with advice or a back-up antibiotic prescription (delayed prescription), taking account of:
    • evidence that antibiotics make little difference to how long symptoms last (on average, they shorten symptoms by about 16 hours)
    • evidence that most people feel better after 1 week, with or without antibiotics
    • the unlikely event of complications if antibiotics are withheld
    • possible adverse effects, particularly diarrhoea and nausea
  • updated guidance states (2)
    • given the current high prevalence of Group A streptococcus (GAS), and the increased likelihood of GAS as cause of sore throat in children, the current CPR sore has been adjusted, with a recommendation to prescribe antibiotics to children with a FeverPAIN score of 3 or more
      • continue to follow clinical judgement as usual

People who are most likely to benefit from an antibiotic (FeverPAIN score of 4 or 5, or Centor score of 3 or 4)

  • consider an immediate antibiotic prescription, or a back-up antibiotic prescription, taking account of:
    • the unlikely event of complications if antibiotics are withheld
    • possible adverse effects, particularly diarrhoea and nausea.
    • when an immediate antibiotic prescription is given, as well as the general advice (see notes), give advice about seeking medical help if symptoms worsen rapidly or significantly or the person becomes systemically very unwell
  • updated guidance states (2)
    • given the current high prevalence of Group A streptococcus (GAS), and the increased likelihood of GAS as cause of sore throat in children, the current CPR sore has been adjusted, with a recommendation to prescribe antibiotics to children with a FeverPAIN score of 3 or more
      • continue to follow clinical judgement as usual

People who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high-risk of complications

  • offer an immediate antibiotic prescription with advice or further appropriate investigation and management
  • refer people to hospital if they have acute sore throat associated with any of the following:
    • a severe systemic infection
    • severe suppurative complications (such as quinsy [peri-tonsillar abscess] or cellulitis, parapharyngeal abscess or retropharyngeal abscess or Lemierre syndrome)

Notes:

  • General advice about sore throat management
    • the usual course of acute sore throat (can last around 1 week)
    • managing symptoms, including pain, fever and dehydration, with self-care
    • reassess at any time if symptoms worsen rapidly or significantly, taking account of: alternative diagnoses
      • such as scarlet fever or glandular fever
      • any symptoms or signs suggesting a more serious illness or condition
      • previous antibiotic use, which may lead to resistant organisms
  • Back-up prescription
    • a back-up (delayed) prescription is one that is given in a way to delay the use of a medicine (usually an antibiotic), and with advice to only use it if symptoms worsen or don't improve within a specified time. The prescription may be given during the consultation (which may be a post-dated prescription) or left at an agreed location for collection at a later date
    • when a back-up antibiotic prescription is given, as well as the general advice, give advice about:
      • an antibiotic not being needed immediately
      • using the back-up prescription if symptoms do not start to improve within 3 to 5 days or if they worsen rapidly or significantly at any time
      • seeking medical help if symptoms worsen rapidly or significantly or the person becomes systemically very unwell.

Reference:

Related pages:

Streptococci