Sore throat (acute): antimicrobial prescribing. NICE NG84, January 2018

This guideline sets out an antimicrobial prescribing strategy for acute sore throat. It aims to limit antibiotic use and reduce antimicrobial resistance. Acute sore throat is often caused by a virus, lasts for about a week, and most people get better without antibiotics. Withholding antibiotics rarely leads to complications. The guideline includes recommendations on managing acute sore throat, including advice when an antibiotic is not needed, choice of antibiotic when a back-up or immediate prescription is needed, and self-care.

MANAGEMENT

Acute sore throat, including pharyngitis and tonsillitis is self-limiting and often triggered by a viral upper respiratory tract infection.

Symptoms can last for about 1 week, but most people will get better within a week without antibiotics, regardless of cause – bacterial or viral.

For children under 5 presenting with fever, refer to NICE CG160. https://www.nice.org.uk/guidance/cg160

For older children and adults, use FeverPAIN or Centor criteria to determine who might benefit from antibiotic therapy.

FeverPAIN criteria

• Fever during previous 24 hours
• Purulence (pus on tonsils)
• Attend rapidly (within 3 days of onset of symptoms)
• Severely Inflamed tonsils
• No cough or coryza (inflammation of mucus membranes in the nose)

Each criterion scores 1 point (maximum score, 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause.

Centor criteria

• Tonsillar exudate
• Tender anterior cervical lymphadenopathy or lymphadenitis
• History of fever (over 38oC)
• Absence of cough

Each criterion scores 1 point (maximum score, 4). A score of 3 or 4 is more likely to be associated with streptococcus infection.

Give advice about:

• The usual course of acute sore throat (about 1 week)
• Managing symptoms, including pain, fever and dehydration (See self-care, below)

Reassess at any time if symptoms worse rapidly or significantly. Consider:

• Alternative diagnoses, e.g. scarlet fever or glandular fever
• Any symptoms or signs suggesting a more serious condition
• Previous antibiotic use, which may lead to resistant organisms

Complications of sore throat caused by Group A beta-haemolytic streptococcus (GABHS) infection are rare but can include quinsy, acute otitis media, or acute sinusitis.

People who are unlikely to benefit from an antibiotic

FeverPAIN score of 0 or 1, Centor score 0, 1 or 2

• Do not offer an antibiotic prescription
• Explain why an antibiotic is not needed

– Antibiotics make little difference to how long symptoms last (on average, shorten duration of symptoms by about 16 hours)

– Most people feel better after 1 week, with or without antibiotics

– Complications are unlikely if antibiotics are withheld

– Antibiotics can cause side effects, e.g. diarrhoea and nausea

• Give advice to seek 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 back-up antibiotic prescription
• Reinforce advice above
• Advise that antibiotic is not needed immediately
• Use back-up prescription if symptoms do not start to improve in 3 – 5 days or if they worsen rapidly or significantly at any time
• Seek medical help if symptoms worsen rapidly or significantly or if the person becomes systemically very unwell.

People who are most likely to benefit from an antibiotic

FeverPAIN score of 4 or 5, Centor score of 3 or 4

• Consider an immediate antibiotic prescription, taking account of

– The unlikely event of complications if antibiotics are withheld

– Possible adverse effects

• Give advice about when to seek medical help, as above.

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

• Offer an immediate antibiotic prescription
• Refer to secondary care if they have evidence of

– Severe systemic infection (See NICE guideline NG51 on sepsis https://www.nice.org.uk/guidance/ng51 )

– Severe suppurative complications such as quinsy, cellulitis, parapharyngeal or retropharyngeal abscess or Lemierre syndrome (a rare complication of tonsillitis).

SELF-CARE

• Consider paracetamol or, if suitable or preferred, ibuprofen for pain or fever
• Advise about adequate intake of fluids
• Medicated lozenges containing either a local anaesthetic, NSAID or antiseptic may help to alleviate pain but only marginally
• There is no evidence for the benefits of non-medicated lozenges, mouthwashes or for local anaesthetic mouth spray used on its own.

CHOICE OF ANTIBIOTIC

Antibiotics for adults aged 18 years and over

First line: Phenoxymethylpenicillin, 500mg four times a day or 1000mg twice a day for 5 – 10 days

Alternative first choices for penicillin allergy or intolerance

Clarithromycin, 250mg – 500mg twice a day for 5 days,

OR

Erithromycin, 250mg – 500mg four times a day or 500mg – 1000mg twice a day for 5 days.

Consult BNF for appropriate use and dosing in hepatic or renal impairment, pregnancy and breastfeeding.

Antibiotics for children and young people under 18 years

First line: Phenoxymethylpenicillin:

1 – 11 months, 62.5mg four times a day or 125mg twice a day for 5 – 10 days

1 – 5 years, 125mg four times a day or 250mg twice a day for 5 – 10 days

6 – 11 years, 250mg four times a day or 500mg twice a day for 5 – 10 days

12 – 17 years, 500mg four times a day or 1000mg twice a day for 5 – 10 days

Alternative first choices for penicillin allergy or intolerance

Clarithromycin

1 month to 11 years

Under 8kg, 7.5mg/kg twice a day for 5 days

8 – 11kg, 62.5mg twice a day for 5 days

12 – 19kg, 125mg twice a day for 5 days

20 – 29kg, 187.5mg twice a day for 5 days

30 – 40kg, 250mg twice a day for 5 days

12 – 17 years, 250mg – 500mg twice a day for 5 days

OR

Erithromycin

1 month – 1 year, 125mg four times a day or 250mg twice a day for 5 days

2 – 7 years, 250mg four times a day or 500mg twice a day for 5 days

8 – 17 years, 250mg – 500mg four times a day or 500mg – 1000mg twice a day for 5 days

Consult BNF for appropriate use and dosing in hepatic or renal impairment

*Age bands apply to children of average size. In clinical practice, the prescriber should also consider other factors including severity of the condition and the child’s size compared with the average of children of the same age.

NICE NG84. Sore throat (acute): antimicrobial prescribing https://www.nice.org.uk/guidance/ng84