Acute sore throat

Update 2017
Philippe Odeurs, Jan Matthys, Marc De Meyere, Lieve Peremans,
Paul Van Royen

Commissioned by Working Group Developm ent of Prim ary Care Guidel ines
Content
GENERAL 3
INCIDENCE/PREVALENCE 4
ETIOLOGY 4
DIAGNOSIS 5
WHAT TO LOOK OUT FOR WHEN TAKING THE HISTORY AND CONDUCTING A CLINICAL EXAMINATION OF
A PATIENT WITH ACUTE SORE THROAT. 5
HOW IS ACUTE SORE THROAT DIAGNOSED? 6
WHAT ARE THE WARNING SIGNS IN THE CASE OF ACUTE SORE THROAT AND WHEN SHOULD A PATIENT
WITH ACUTE SORE THROAT BE REFERRED? 7
TREATMENT 7
DRUG TREATMENT 7
WHICH SYMPTOMATIC TREATMENT CAN BE PRESCRIBED? 7
WHICH PATIENTS SHOULD BE TREATED WITH ANTIBIOTICS? AND WHICH ANTIBIOTIC IS RECOMMENDED? 8
NON-DRUG TREATMENT 8
WHAT EXPLANATION MUST BE GIVEN TO A PATIENT WHO IS NOT PRESCRIBED ANTIBIOTICS? 8
WHAT APPROACH IS RECOMMENDED FOR PERSISTENT BACTERIAL (PHARYNGO)TONSILLITIS? 9
PRACTICAL IMPLEMENTATION 9
PATIENT COMMUNICATION 9
FOLLOW-UP 9

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General
This is the English summary. The complete guideline is available in Dutch and
French at ebp-guidelines.be.

Description of the topic

This guideline consists of recommendations for the diagnosis and treatment of
acute sore throat with infectious origin, for all doctors active in outpatient
primary care. Recommendations are provided concerning which patients with
acute sore throat can be prescribed antibiotics.

Target population
The guideline is applicable for children (from 3 years) and adults with acute
sore throat.

Definitions
The guideline is applicable for children (from 3 years) and adults with acute
sore throat.

Tonsillitis is an infection of the mucosal membranes and parenchyma of the

tonsilla palatina. Tonsillitis can occur as an isolated condition or as part of a
global pharyngitis.

Pharyngitis is an infection of the pharyngeal mucosal membrane.

Pharyngotonsillitis: because there is little clinical difference between tonsillitis

and pharyngitis, the term used is usually acute pharyngotonsillitis. Symptoms of
acute pharyngotonsillitis are fever, sore throat, difficulty swallowing and painful
cervical lymph glands with possible obstruction of airways accompanied by
breathing through the mouth, snoring and/or apnoea.

Acute: present for less than 14 days.

Persistent pharyngotonsillitis: definition according to the number of episodes

per year or per consecutive years important: in the case of 7 or more
documented episodes of clinically significant and adequately treated acute
sore throat in the previous year or five such episodes in each of the two prior
years or 3 of such episodes in each of the three prior years.

Peritonsillar abscess: tonsillitis that spreads and leads to infiltrate and finally an
abscess forms between the tonsil and the lateral pharyngeal wall.

By acute sore throat we mean acute tonsillitis and/or acute pharyngotonsillitis.

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Incidence/prevalence
Acute sore throat is a frequent complaint in the GP setting (3% of all reasons for
encounter or RFE). Acute tonsillitis is one of the twenty most commonly
diagnosed conditions in the GP setting (approx. 20 per 1000 patient years in
annual contact group).

Etiology
 No pathogenic germ in 30%.
Non-infectious causes for acute sore throat: irritation as a result of
exposure to irritants, gastro-oesophageal reflux, allergy, iatrogenic
causes (radiotherapy, medication), endocrine and other general causes
(menopause, hypothyroidism, vitamin A deficiency, diabetes, …) or an
infection situated higher (adenoiditis, rhinosinusitis).
 Viral origin in 40% of cases (rhinovirus, coronavirus, adenovirus,
(para)influenza virus)
 In 30% of cases pathogenic streptococci, of which 1/3 are carrier
(without infection or disease symptoms).
Group A-beta-haemolytic streptococcus (GABHS; Streptococcus
pyogenes) is the most frequently occurring bacterial trigger, followed by
other haemolytic streptococci (group C, G and other),
Enterobacteriaceae, Staphylococcus aureus.

Risk groups and factors

Patients with:
 cancer who are undergoing chemo- or radiotherapy,
 acute rheumatism,
 reduced general immunity due to HIV infection, immune disorders,
asplenia, severe alcohol abuse, intravenous drug use, diabetes mellitus
or due to use of medication that reduces immunity such as oral
corticosteroids, cytostatics, disease-modifying antirheumatic drugs
(DMARDs), thyreostatics, phenytoin, neuroleptics and
immunosuppressants,
 group A beta-haemolytic streptococcal epidemic (GABHS) in a closed
community,
 toxic syndrome (severe pathological condition with high fever, low blood
pressure and gastrointestinal symptoms such as vomiting and diarrhoea),
 relapses of acute sore throat ≥ 5 per year (two years after each other),
 recent prosthesis surgery and heart valve disorder with risk of
endocarditis.

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This list is not exhaustive. On the basis of the risk factors, medical history and
clinical picture, the GP makes an assessment of who is (may be) an at-risk
patient (e.g. patients with diabetes, heart failure, valve disorders, asthma, …).

Diagnosis
What to look out for when taking the history and conducting a
clinical examination of a patient with acute sore throat.
During the intake, pay attention to the ideas, concerns and expectations (ICE)
of the patient and the psychosocial elements that may influence these.
(GRADE 1C)
By taking a history and conducting a clinical examination, check whether there
is another pathology present (including mononucleosis, peritonsillar abscess),
or whether the patient is seriously ill and/or belongs to an at-risk group. (GPP)

History taking questions about the following elements:

 the duration of the pain: if the pain has been present for more than three
days, there is little chance of antibiotics having an effect.
Sore throat that persists for more than 7 days may have other causes
(environmental factors, smoking);
 how the symptoms are progressing: progressive increase or gradual
decrease?
 the symptoms: general pathological signs (different feeling of illness than
usual, irritability, something not right), coughing (absence of cough
makes bacterial infection more likely), fever (temperature ≥ 38.5°C rectal
measurement), saliva production, difficulty swallowing or problems
opening mouth (cave: abscess formation (peritonsillar abscess)), fatigue
that continues more than 7 days (infectious mononucleosis, leukaemia),
 when suspecting STI: ask whether orogenital contact has taken place.

Clinical examination
 measure temperature (fever with chills may indicate a severe bacterial
infection), blood pressure and pulse;
 if infectious mononucleosis or leukaemia is suspected, examine glands,
liver, spleen;
 inspect mouth and throat for the presence of:
o deposit on tonsils (does not necessarily indicate bacterial
infection), peritonsillar oedema, problems opening mouth
(trismus),
o uni-/bilateral infiltration (unilateral e.g. in the case of Plaut-Vincent
angina and peritonsillar abscess),
o displacement of uvula and/or displacement of tonsil to medial
(abscess),

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 o erosion or ulceration: ulcers, herpes,
o pharyngitis only and/or also infection of tonsils,
o petechiae: infectious mononucleosis, streptococci,
staphylococci, meningococci.
 palpate the neck for presence of:
o swollen and/or pressure-sensitive glands in the neck,
o enlarged lymph glands in other areas than submandibular (may
indicate mononucleosis),
o enlarged, painful thyroid (may indicate sub-acute thyroiditis),
o other infectious foci: sinuses, ears, teeth, lower respiratory tract.
 skin inspection:
o perioral paleness, cherry-red tonsils, raspberry tongue, exanthema
and signs of Pastia’s lines (red lines in groin and armpits) may
indicate scarlet fever,
o if infectious mononucleosis or leukaemia is suspected, further
examination of the glands, liver, spleen is recommended,
o skin colour (cyanosis?),
o for petechiae in seriously ill patient.

For various reasons it is not clinically relevant to conduct further diagnostics for
GABHS tonsillitis. There should be no distinction made between bacterial and
viral infections, but rather between patients who are at risk and those who are
not. Moreover, there is no ideal test for diagnosing GABHS tonsillitis.

How is acute sore throat diagnosed?

Make a distinction between non-severe and severe forms of throat infection.
Severe forms are pharyngotonsillitis in a seriously ill patient, peritonsillar
infiltration and epiglottis. (GPP)

 Seriously ill: something not right with general disease symptoms (fever
≥38.5°C, serious malaise, confined to bed), abnormal course of the illness
and/or combination of serious symptoms and findings upon clinical
examination (such as problems opening mouth, difficulty swallowing and
drooling/excess saliva);
 peritonsillar infiltration: unilateral symptoms, such as abnormal status of
the anterior pharyngeal arch, deviation of the uvula to the healthy side
or movement of the tonsil downwards and median due to the swelling,
with possible radiating pain to the ipsilateral ear, severe difficulties with
swallowing, drooling due to swallowing difficulty, inability to open the
mouth, enlarged lymph glands in the neck and voice change;

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  epiglottitis:
o in patients with fever, sore throat and a typical history with acute,
rapidly progressing pain, pain when swallowing, voice change,
drooling, or in a less typical history if there is a discrepancy
between the severity of the symptoms and very few abnormal
findings upon examination of the throat;
o where there are signs of upper respiratory tract obstruction (use of
accessory muscles of respiration, flaring nostrils, inspiratory stridor,
tripod position whereby the patient sits leaning over something
with tongue hanging out of an open mouth, so that the saliva can
run out, sometimes leaning on both arms) and sore throat;
o In the case of pain upon palpation of the larynx and swollen lymph
glands.

In the case of a non-severe form of throat infection, determine whether there

is an increased risk of complications. (GPP)

What are the warning signs in the case of acute sore throat and
when should a patient with acute sore throat be referred?
Sore throat in combination with severe stridor and/or respiratory insufficiency
and/or serious difficulty swallowing is an absolute indication for referral to the
hospital. (GPP)

In the case of breathing difficulties, avoid any outpatient attempts to

examine the throat. (GPP)

Treatment
Drug treatment

Which symptomatic treatment can be prescribed?

To alleviate acute sore throat symptoms, we recommend paracetamol,
maximum 4 x 1 g per day for adults and maximum 60 mg/kg per day for
children. Ibuprofen is a good alternative, but keep in mind the possible side
effects (gastrointestinal side effects), comorbidity (with risk of dehydration, such
as renal insufficiency and diarrhoea) and concomitant medication. The dose
is maximum 3 x 400 mg per day for adults and 7 to maximum 10 mg per kg
body weight per dose, maximum three times a day for children. (GRADE 1A)

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Which patients should be treated with antibiotics? And which
antibiotic is recommended?
Consider prescribing antibiotics to seriously ill patients and at-risk patients.
Weigh up the benefits of antibiotics against the side effects, the effect on the
normal microflora, the increased risk of resistance, the medicalisation and the
cost price. (GRADE 2C)

If antibiotics are recommended, then preference should go to

phenoxymethylpenicillin (= penicillin V) three times a day for 7 days. (GRADE
1A)
Overview of recommended antibiotics and doses:

First choice: (GRADE 1B)

phenoxymethylpenicillin * Child: 50,000 IE/kg per day in 3 to 4 doses for 7 days
* Adult: 3,000,000 IE per day in 3 doses for 7 days (between
meals)
Alternative in the event of unavailability of phenoxymethylpenicillin or due to non-IgE-
mediated penicillin allergy: (GRADE 1C)
cefadroxil * Child: 30 mg/kg per day in 2 to 3 doses for 7 days
* Adult: 2 g per day in 2 doses for 7 days
cephalexin * Adult: 2 g per day in 2 to 4 doses for 7 days
Alternative in the case of IgE-mediated penicillin allergy: (GRADE 1C)
clarithromycin * Child: 15 mg/kg per day in 2 doses for 7 days
* Adult: 500-1000 mg per day in 2 doses for 7 days
azithromycin * Child: 10 mg/kg per day in 1 dose for 3 days; or first day 10
mg/kg in 1 dose, then 5 mg/kg per day in 1 dose for 4 days.
* Adult: 500 mg per day in 1 dose for 3 days; or first day 500
mg in 1 dose, then 250 mg per day in 1 dose for 4 days.
roxithromycin * Adult: 300 mg per day in 2 doses for 7 days
Pharmaceutical compounding on basis of phenoxymethylpenicillin
Syrup for children R/ phenoxymethylpenicillin potassium syrup sugar-free for
children at 32.5 mg/ml or 50,000 IE/ml TMF S/50,000 IE/kg per
day in 3 to 4 doses (= 1 ml/kg per day in 3 or 4 doses)
Syrup for adults R/ phenoxymethylpenicillin potassium syrup sugar-free for
adults at 130 mg/ml or 200,000 IE/ml TMF S/ 3,000,000 IE per
day in 3 doses (= 3 x 5 ml per day)

Non-drug treatment

What explanation must be given to a patient who is not prescribed

antibiotics?
Inform the patient that there is usually no point in starting antibiotics for acute
sore throat (GRADE 1A) – because they have little effect on the duration and
nature of the symptoms. They are also unable to prevent acute rheumatism,

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acute post-streptococcal glomerulonephritis, local complications and
recurrent infections.

What approach is recommended for persistent bacterial

(pharyngo)tonsillitis?
In children and adults with mild acute sore throat we recommend a ‘watchful
waiting’ approach in preference to tonsillectomy. (GRADE 1A)

Consider referral for tonsillectomy in the event of the following findings (GRADE
2C):
 The episodes of acute sore throat are due to acute tonsillitis.
 The episodes of acute sore throat make normal functioning impossible.
 There are 7 or more documented episodes of clinically significant and
adequately treated sore throat in the last year or 5 such episodes in each
of the last two years or three such episodes in each of the last three years.

Practical implementation
Patient communication
If antibiotics are not prescribed - Inform the patient that there is usually no point
starting antibiotics for acute sore throat (GRADE 1A) – because they have little
effect on the duration and nature of the symptoms. They are also unable to
prevent acute rheumatism, acute post-streptococcal glomerulonephritis, local
complications and recurrent infections.
If antibiotics are prescribed, inform the patient about the possible side effects
(nausea, diarrhoea, skin rash, itching, anaphylactic reactions). (GPP)
All patients should be given information about possible complications:
o Increased problems swallowing and sore throat may indicate
peritonsillar abscess, Lemierre’s syndrome.
o Persistent (throat)pain, fatigue or being ill may indicate infectious
mononucleosis, leukaemia. (GPP)

Follow-up
In a patient who comes to a consultation with acute sore throat, follow-up is
not normally provided. Follow-up is necessary if the symptoms do not clear up
after 2 days or if they get worse after 1 or 2 days. Risk factors are a stiff neck,
high fever, chills (more than 39° C), night sweats and unilateral neck swelling.
Also prioritise follow-up of those patients who are prescribed antibiotics but
show no improvement after 2 days (GPP)