Assessing and managing sore throat

Case scenario

You conduct a MedsCheck for a regular patient, Mrs Nguyen. While undertaking the MedsCheck interview, Mrs Nguyen mentions that she and her husband have had sore throats for the past 24 hours. The symptoms are not severe, and they have had negative test results for COVID-19 infection. They are also experiencing runny noses and slight coughs.

Introduction

Sore throat is caused by inflammation of the upper respiratory tract, usually the pharynx (pharyngitis), larynx, or tonsils (tonsillitis) and rarely the epiglottis.^1,2 Sore throat is a symptom rather than a diagnosis.¹ Although usually mild and self-limiting, it can be painful and warrants careful investigation by pharmacists.

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Gather patient information

Clinical features

Patients with sore throat may find it painful to swallow and may describe their throat as ‘dry’ or ‘scratchy’.³ Pain may worsen when patients swallow or talk.⁴

If viral in origin, cold or flu-like symptoms (e.g. cough, nasal congestion) may also be present.^2,3 Particularly in younger patients, recurrent sore throat with fever and lymph node swelling may suggest glandular fever.¹

Sore throat caused by streptococcal infection may present with signs and symptoms such as sudden onset, fever >38 °C, red and swollen tonsils (sometimes with white patches or pus), swollen cervical lymph nodes, and rash.^2,3

Neither the severity nor the duration of a sore throat is a reliable indicator of whether the cause is viral or bacterial.¹

It can also be challenging to identify a viral or bacterial cause based on clinical features.²

Causes of sore throat 

Sore throat is most commonly caused by viruses, such as influenza, COVID-19, and those that cause chicken pox, croup and the common cold.^1,2,4,5 Bacterial infection is less common, and most cases are due to Streptococcus pyogenes (group A Streptococcus), which is seen more often in children. This infection is usually self- limiting; however, some patient groups are at higher risk of developing acute rheumatic fever, especially with recurrent infections. The Therapeutic Guidelines provides details of patients considered to be at high risk of developing acute rheumatic fever.²

Other causes of sore throat include^2,3,4,6-8:

• allergies (e.g. animal dander, moulds, dust, pollen)
• throat dryness from breathing dry indoor air or breathing through the mouth
• environmental irritants (e.g. smoking, second-hand smoke, chemicals)
• drinking alcohol or eating spicy foods
• muscle strain (from talking loudly or yelling, or talking continuously for a long time)
• gastro-oesophageal reflux disease (GORD)
• tumours of the throat; other symptoms may include hoarseness, swallowing difficulties, noisy breathing, a lump in the neck and blood in the saliva or phlegm
• medicine-related neutropenia/agranulocytosis or immunosuppression (e.g. with cytotoxics, immunosuppressants, enalapril, clozapine, carbamazepine, naproxen); often presents with other signs of infection such as fever/chills
• medicines such as inhaled medicines (e.g. indacaterol, ipratropium, glycopyrronium), sumatriptan and fluticasone nasal sprays, and oral nicotine replacement therapy.

Assess patient needs 

Diagnosis and referal

When a patient presents with a sore throat, in addition to usual history taking (e.g. medicines already trialled, allergies), pharmacists should ask about^1,5,6,8:

• symptom duration
• other symptoms and symptom severity
• age (if patient not present/age not apparent)
• recent trauma to throat (e.g. hot drinks, falls)
• vaccination status
• other medicines (especially immunosuppressants, cancer medicines, clozapine). 

Patients should see their doctor if they have any symptoms that are severe or concerning or if the following are present with sore throat^2–4,8:

• Earache
• fever >38 °C
• lump in neck
• blood in saliva/phlegm
• joint pain or swelling
• rash
• sore throat for more than 1 week
• hoarseness for more than 2 weeks
• symptoms worsen or do not improve within 3–7 days, or new symptoms develop (e.g. vomiting, dehydration, rigors)
• tonsillar exudate with fever and swollen glands
• recurrent sore throat.

Urgent medical attention is required if the patient experiences any of the following^1,2:

• breathing difficulties or stridor
• stertor (sound like snoring)
• difficulty opening mouth
• drooling
• neck swelling
• torticollis (neck twisted to one side)
• muffled voice
• severe pain (including neck pain)
• one-sided throat pain
• dysphagia
• signs of dehydration
• systemically unwell.

Patients should also seek immediate medical attention if they are immuno-compromised or take medicines that can cause neutropenia/agranulocytosis.^1,8

Treatments

Treatment for sore throat will depend on the cause. If caused by a virus, the infection will resolve on its own. If the cause is a bacterial infection, antibiotics may be required.⁴

To relieve pain and/or fever, paracetamol or non-steroidal anti-inflammatory drugs (e.g. ibuprofen) maybe used.^1,2 Topical products include lozenges, gargles and sprays. These usually contain anaesthetic, anti-inflammatory and/or antiseptic ingredients; however, there is little evidence they are of benefit.^2,5

Patients who have severe symptoms (e.g. severe throat pain, dysphagia, drooling) may be prescribed a corticosteroid to assist with pain (e.g. prednisone/prednisolone ).² A Cochrane review found that the use of corticosteroids for sore throat reduced the mean time to pain relief onset by 6 hours, and the mean time to complete pain resolution by 11.6 hours.⁹

Patients should be referred if they have severe symptoms or a rash (see ‘Diagnosis and referral’). Consideration for empirical antibiotics is given to patients with symptoms such as severe sore throat, dysphagia or rash.² If antibiotics are being considered, a throat swab should be collected if possible (preferably before antibiotics are started). These results and the patient’s clinical progress will be used to inform the decision to use or continue antibiotics.² Antibiotics can be considered in patients who have a confirmed streptococcal infection and ongoing symptoms.²

Patients at high risk of acute rheumatic fever should receive empirical antibiotics for streptococcal infection, regardless of whether the symptoms suggest a viral or bacterial cause.²

If antibiotics are required for streptococcal infection, phenoxymethyl-penicillin is first line.² Intramuscular benzathine benzylpenicillin can be used if patients cannot adhere to the full treatment course for oral antibiotics, or if oral treatment is not tolerated.²

For patients with hypersensitivity to penicillins, the recommended treatment is cefalexin (if delayed non-severe hypersensitivity to penicillins) or azithromycin (if immediate – both non-severe and severe – or delayed severe hypersensitivity to penicillins).² The Therapeutic Guidelines provides information on dosing regimens.²

Patients should understand the limitations of antibiotic treatment.¹ A Cochrane review found antibiotics are moderately beneficial in reducing the risk of complications and reducing symptom duration of sore throat.¹⁰ However, the effect on symptoms was small, so the decision to prescribe antibiotics should be made on an individual basis.¹⁰

In general, most people will feel better in 1 week regardless of whether antibiotics are used. Complications from sore throat are uncommon. Antibiotics have adverse effects associated with their use, and overuse contributes to antimicrobial resistance.^1,11

If the sore throat is due to a cause other than viral or bacterial infection, other treatment or management strategies will be used depending on the cause.⁴

Non-pharmacological strategies can be tried to relieve symptoms of sore throat. These include^1,3,6:

• sucking on ice 
• using a clean humidifier or cool mist vaporiser
• gargling with salt water
• drinking plenty of fluids to avoid dehydration.

Patient advice and education

Pharmacists should provide advice to patients on the signs and symptoms that require further medical assessment. Patients should be advised that most cases of sore throat are self-limiting, and antibiotics are not usually required. Children with suspected streptococcal  infection, or suspected or confirmed viral infection, should not attend school or day care while they have symptoms. If S. pyogenes infection is confirmed, it is generally recommended that children be excluded from school/day care for 24 hours after receiving their first dose of antibiotics and until they feel well.^2,6 However, pharmacists should consult local public health guidelines for the most current guidance in their area.² Exclusion of contacts is not required.⁶

If patients are prescribed antibiotics, they should be advised to adhere to the full treatment course.²

Pharmacists can provide advice on ways to reduce the risk of sore throat due to infection. Prevention strategies can be found in the Australian Pharmaceutical Formulary and Handbook (APF) common colds guide.⁶

Knowledge to practice 

Pharmacists can assess symptoms, provide advice on symptomatic management, and refer patients for medical assessment when required.¹¹ Pharmacists can also provide education to patients on the role of antibiotics for sore throat, including their limited role and the potential risks and benefits associated with their use.²

Conclusion

Sore throat can have various causes but is most commonly due to viral infection. When patients present with sore throat, pharmacists should take a thorough patient history to determine the most likely cause and whether referral for further medical assessment is required. Antibiotics should be prescribed for patients at high risk of acute rheumatic fever.

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Key points

• Sore throat is caused by inflammation of the upper respiratory tract. 
• Viral infection is the most common cause of a sore throat. 
• Treatment of sore throat will depend on the cause. 
• Antibiotics have a limited role in treating sore throat.

References

1. Hazell T. Sore throat. 2022. At: https://patient.info/doctor/sore-throat-pro
2. Sore throat. Therapeutic guidelines; [updated 2022 Aug]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Antibiotic&topicfile=sore-throat&guidelinename=Antibiotic&sectionId=toc_d1e47#toc_d1e47
3. Centers for Disease Control and Prevention. Sore throat. 2021. At: www.cdc.gov/antibiotic-use/sore-throat.html
4. Mayo Clinic. Sore throat. 2021. At: www.mayoclinic.org/diseases-conditions/sore-throat/symptoms-causes/syc-20351635
5. Rossi S, ed. Ear, nose and throat drugs. Australian medicines handbook [updated 2023 Jan]. At: https://amhonline.amh.net.au/chapters/ear-nose-throat-drugs/drugs-mouth-throat-conditions/mouth-throat-conditions
6. Sansom LN, ed. Australian pharmaceutical formulary and handbook. 25th edn. Canberra: Pharmaceutical Society of Australia; 2021.
7. Renner B, Mueller CA, Shepherd A. Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat). Inflamm Res 2012;61(10):1041-52.
8. Rutter P, Newby D. Community pharmacy: symptoms, diagnosis and treatment. 5th edn; Enhanced digital version. Edinburgh; New York: Elsevier; 2021.
9. de Cassan S, Thompson MJ, Perera R, et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev 2020;5(5):CD008268.
10. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev 2021;12(12):CD000023.
11. Mantzourani E, Hicks R, Evans A, et al. Community pharmacist views on the early stages of implementation of a pathfinder sore throat test and treat service in Wales: an exploratory study. Integr Pharm Res Pract 2019;8:105-13.

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