Pharyngitis / Sore Throat / Tonsillitis

Consider a no or delayed antibiotic strategy ^A+

Doses are oral and for adults unless otherwise stated. Visit the Health Products Regulatory Board website or the printed Irish Medicines Formulary for drug SPCs, dosage, contraindications, interactions, or IMF/BNF/BNFC/MIMS. See guidance on dosing in children for quick reference dosage/weight guide. Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion). Statins can interact with some antibiotics and increase the risk of rhabdomyolysis. Amiodarone and drugs which prolong the QT interval can interact with many antibiotics. Many antibiotics increase the risk of bleeding with anticoagulants. Please refer to our Drug Interactions Table for further information.

Comments from Expert Advisory Committee

1. The majority of sore throats are viral; most patients do not benefit from antibiotics. Consider a delayed antibiotic strategy and explain soreness will take about 8 days to resolve.

The FeverPAIN scoring system helps to identify those who are most likely to benefit from antibiotics. One point is assigned to each of the following five criteria:

presence of Fever; Pus on the tonsils;

Attendance within three days of onset of symptoms; severely Inflamed tonsils;

No cough or coryzal symptoms present.

Treatment with immediate antibiotics should be considered if the score is 4 or 5; offer a deferred antibiotic to those with scores of 2 or 3; do not offer an antibiotic to those with 0 or 1.

Those with a history of otitis media may benefit more from antibiotics. A-
Antibiotics only shorten duration of symptoms by 8 hours. A+

2. Antibiotics to prevent otitis media NNT 200, ^A+ Quinsy NNT >4000. ^B

3. Penicillin for 7 days is more effective than 3 days. ^B+ Twice daily higher dose can also be used. ^A- QDS may be more appropriate if severe. ^D

4. Phenoxymethylpenecillin is effective treatment for Invasive Group A strep infections iGAS -use higher dose qds for 10 days . See GP Information on Invasive Group A Strep from ICGP

5. Phenoxymethylpenicillin suspension is available in two flavours; Calvepen® (caramel) and Kopen® (orange).

Symptomatic Relief

• Discomfort on swallowing – lozenges containing benzocaine or flurbiprofen. Use oral parecetomol or ibuprofen for stronger pain relief
• Sore, ‘tickly’ throat – demulcent pastilles. Sucking a lozenze or pastille promotes saliva production which lubricates and soothes the throat. Main disadvantage; high sugar content though sugar-free preparations are available.
• Local analgesia - antiinflammatory spray or mouthwash (e.g. benzydamine)
• Weak evidence supports the use of a once off oral dose of 10mg dexamethasone in adults with sore throat. This has been shown to reduce throat pain at 48 hours compared to placebo.

Treatment

Consider a no or delayed antibiotic strategy.^A+

If antibiotics deemed clinically indicated: