Recommendations

Guidance

1.1 Managing acute sore throat
1.2 Self-care
1.3 Choice of antibiotic

Recommendations

1.1 Managing acute sore throat

All people with acute sore throat

1.1.1 Be aware that:

acute sore throat (including pharyngitis and tonsillitis) is self‑limiting and often triggered by a viral infection of the upper respiratory tract
symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus).

1.1.2 Assess and manage children under 5 who present with fever as outlined in the NICE guideline on fever in under 5s.

1.1.3 Use FeverPAIN or Centor criteria to identify people who are more likely to benefit from an antibiotic and manage in line with recommendations 1.1.4 to 1.1.13.

1.1.4 Give advice about:

the usual course of acute sore throat (can last around 1 week)
managing symptoms, including pain, fever and dehydration, with self-care (see the recommendations on self-care).

1.1.5 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.

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

1.1.6 Do not offer an antibiotic prescription.

1.1.7 As well as the general advice in recommendation 1.1.4, give advice about:

an antibiotic not being needed
seeking medical help if symptoms worsen rapidly or significantly, do not start to improve after 1 week, or the person becomes systemically very unwell.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on no antibiotic.

Full details of the evidence and the committee's discussion are in the evidence review.

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

1.1.8 Consider no antibiotic prescription with advice (see recommendation 1.1.7) or a back-up antibiotic prescription (see recommendation 1.3.1 for choice of antibiotic), 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.

1.1.9 When a back-up antibiotic prescription is given, as well as the general advice in recommendation 1.1.4, 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.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on no antibiotic and back-up antibiotics.

Full details of the evidence and the committee's discussion are in the evidence review.

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

1.1.10 Consider an immediate antibiotic prescription (see recommendation 1.3.1 for choice of antibiotic), or a back-up antibiotic prescription with advice (see recommendation 1.1.9), taking account of:

the unlikely event of complications if antibiotics are withheld
possible adverse effects, particularly diarrhoea and nausea.

1.1.11 When an immediate antibiotic prescription is given, as well as the general advice in recommendation 1.1.4, give advice about seeking medical help if symptoms worsen rapidly or significantly or the person becomes systemically very unwell.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on back-up antibiotics and choice of antibiotic.

Full details of the evidence and the committee's discussion are in the evidence review.

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

1.1.12 Offer an immediate antibiotic prescription (see recommendation 1.3.1 for choice of antibiotic) with advice (see recommendation 1.1.11).

1.1.13 Refer people to hospital if they have acute sore throat associated with any of the following:

a severe systemic infection (see the NICE guideline on sepsis)
severe suppurative complications (such as quinsy [peri-tonsillar abscess] or cellulitis, parapharyngeal abscess or retropharyngeal abscess or Lemierre syndrome).

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on choice of antibiotic.

Full details of the evidence and the committee's discussion are in the evidence review.

1.2 Self-care

All people with acute sore throat

1.2.1 Consider paracetamol for pain or fever, or if preferred and suitable, ibuprofen.

1.2.2 Advise about the adequate intake of fluids.

1.2.3 Explain that some adults may wish to try medicated lozenges containing either a local anaesthetic, a non-steroidal anti-inflammatory drug (NSAID) or an antiseptic. However, they may only help to reduce pain by a small amount.

1.2.4 Be aware that no evidence was found on non-medicated lozenges, mouthwashes, or local anaesthetic mouth spray used on its own.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on self-care.

Full details of the evidence and committee's discussion are in the evidence review.

1.3 Choice of antibiotic

1.3.1 When prescribing an antibiotic for acute sore throat:

follow table 1 for adults aged 18 years and over
follow table 2 for children and young people under 18 years.

**Table 1 Antibiotics for adults aged 18 years and over**
Treatment	Antibiotic, dosage and course length
First-choice oral antibiotic	Phenoxymethylpenicillin: 500 mg four times a day or 1,000 mg twice a day for 5 to 10 days Five days may be enough for symptomatic cure; but a 10-day course may increase the chance of microbiological cure
Alternative first choice for penicillin allergy or intolerance (for people who are not pregnant)	Clarithromycin: 250 mg to 500 mg twice a day for 5 days
Alternative first choice for penicillin allergy in pregnancy	Erythromycin: 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.

See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.

**Table 2 Antibiotics for children and young people under 18 years**
Treatment	Antibiotic, dosage and course length
First-choice oral antibiotic	Phenoxymethylpenicillin: 1 month to 11 months, 62.5 mg four times a day or 125 mg twice a day for 5 to 10 days 1 year to 5 years, 125 mg four times a day or 250 mg twice a day for 5 to 10 days 6 years to 11 years, 250 mg four times a day or 500 mg twice a day for 5 to 10 days 12 years to 17 years, 500 mg four times a day or 1,000 mg twice a day for 5 to 10 days Five days may be enough for symptomatic cure; but a 10-day course may increase the chance of microbiological cure
Alternative first choice for penicillin allergy or intolerance (for people who are not pregnant)	Clarithromycin: 1 month to 11 years: Under 8 kg, 7.5 mg/kg twice a day for 5 days 8 kg to 11 kg, 62.5 mg twice a day for 5 days 12 kg to 19 kg, 125 mg twice a day for 5 days 20 kg to 29 kg, 187.5 mg twice a day for 5 days 30 kg to 40 kg, 250 mg twice a day for 5 days 12 years to 17 years, 250 mg to 500 mg twice a day for 5 days
Alternative first choice for penicillin allergy in pregnancy	Erythromycin: 8 years to 17 years, 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.

See the BNF for children for appropriate use and dosing in specific populations, for example hepatic impairment and renal impairment.

The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age.

For a short explanation of why the committee made these recommendations, see the evidence and committee discussion on antibiotic choice and antibiotic course length.

Full details of the evidence and committee's discussion are in the evidence review.