Pharyngitis, sore throat, tonsillitis

Comments from Expert Advisory Group

  • GPs can use the Respiratory infection information leaflet (including self-care and safety-netting advice) (PDF 488 KB) during consultations with patients presenting with pharngitis / sore throat / tonsillitis where there is no immediate need for an antibiotic.
  • The majority of sore throats are viral in origin. Most patients do not benefit from antibiotics. Consider a delayed antibiotic strategy and explain soreness will take about 7 days to resolve.
  • Antibiotics make little difference to how long symptoms last or the number of people whose symptoms improve.
  • Withholding antibiotics is unlikely to lead to complications.
  • Offer all patients advice about self-care and to seek medical help if symptoms worsen significantly.
  • Reassess if symptoms worsen rapidly or significantly, taking account of: alternative diagnoses such as scarlet fever or glandular fever or any symptoms or signs suggesting a more serious illness or condition.
  • Consider referral to hospital if they have acute sore throat associated with severe systemic infection or severe suppurative complications (such as abscess).
  • If scarlet fever is suspected it is advisable to treat for 10 days duration.
  • HPSC update on group A Streptococcus

FeverPAIN scoring system helps to identify those who are most likely to benefit from antibiotics. This tool has not been assessed in children under 3 years.

Each of the FeverPain criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause. FeverPAIN criteria:

  • Fever
  • Pus on tonsils
  • Attendance within 3 days of onset of symptoms
  • Severely inflamed tonsils
  • No cough or coryzal symptoms present

Score 0-1: Do not offer antibiotic

Score 2-3: Offer delayed antibiotic

Score 4-5: Offer immediate antibiotic prescription

A score of 0 or 1 is thought to be associated with a 13% to 18% likelihood of isolating streptococcus.

A score of 2 or 3 is thought to be associated with a 34% to 40% likelihood of isolating streptococcus.

A score of 4 or 5 is thought to be associated with a 62% to 65% likelihood of isolating streptococcus.

Symptomatic Relief

  • Consider analgesia: paracetamol (or ibuprofen where appropriate).
  • Advise patient about adequate intake of fluids.
  • Patients report symptom relief from using over-the-counter products such as topical anaesthetic sprays and medicated lozenges containing local anaesthetics.
  • Advise to consult pharmacist for symptom relief.

Treatment

Pharngitis / Sore Throat / Tonsillitis Antibiotic Treatment Table

Consider no antibiotic or delayed antibiotic strategy.
Use FEVERPAIN Score to identify those most likely to benefit from antibiotics*.

Score 0-1: Do not offer antibiotic

Score 2-3: Offer delayed antibiotic

Score 4-5: Offer immediate antibiotic prescription

* FeverPAIN tool has not been assessed in children under 3 years
If antibiotics deemed clinically indicated:
Drug Dose Duration Notes
Adults: 1st choice options

Phenoxymethylpenicillin

 

 

666mg every 6 hours
(Calvepen®)

OR 500mg every 6 hours
(Kopen®) 

5 Days#

 

 

Avoid in penicillin allergy.

Recommend to take 30 minutes before a meal or 2 hours after food.

#Depending on clinical response, duration can be extended to 10 days in total. If scarlet fever is suspected it is advisable to treat for 10 days duration.
Adults: 2nd choice options

Amoxicillin 

500mg every 8 hours 

5 days#

Avoid in penicillin allergy.

OR

Cefalexin 

 

500mg every 8 hours

 

5 days#

 

Cephalosporins should not be used in severe penicillin allergy.

OR

Clarithromycin

 

 

 

 

 

500mg every 12 hours 

 

 

 

 

 

5 days#

 

 

 

 

See Macrolide warning and check drug interactions before prescribing.

Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy.

Alternative macrolide for all trimesters of pregnancy: Azithromycin 500mg stat then 250mg every 24 hours from Day 2 to Day 5.

#Depending on clinical response, duration can be extended to 10 days in total. If scarlet fever is suspected it is advisable to treat for 10 days duration.
Children: 1st choice options

Phenoxymethylpenicillin

 

See Phenoxymethylpenicillin dosing for children

 

5 days#

 

Avoid in penicillin allergy.

Recommend to take 30 minutes before a meal or 2 hours after food.
Children: 2nd choice options

Amoxicillin

See Amoxicillin dosing for children

5 days#

Avoid in penicillin allergy.

OR

Cefalexin

 

See Cefalexin dosing for children

 

5 days#

 

Cephalosporins should not be used in severe penicillin allergy.

OR

Clarithromycin

 

See Clarithromycin dosing for children

 

5 days#

 

See Macrolide warning and check drug interactions before prescribing.
#Depending on clinical response, duration can be extended to 10 days in total. If scarlet fever is suspected it is advisable to treat for 10 days duration.

Patient Information

Safe Prescribing (visit the safe prescribing page)

Reviewed September 2024, minor edit November 2024.

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