Sore throat
Most are viral. Use FeverPAIN or Centor, look for a quinsy, never examine a drooling child, and treat strep throat properly to prevent rheumatic fever.
A 19-year-old has a sore throat for 2 days, fever 38.5 °C, pus on both tonsils and tender lymph nodes at the front of the neck. No cough.
A 25-year-old woman has severe right-sided throat pain for 4 days, can't swallow her saliva, can only open her mouth 2 fingers wide, and her voice sounds like she has a hot potato in her mouth. Her uvula is pushed to the left.
Who needs antibiotics, and who needs ENT today?
- Airway and droolingStridor, drooling, muffled voice, can't swallow saliva: epiglottitis or abscess.
- QuinsyOne-sided swelling, uvula pushed away, trismus, hot potato voice: ENT for drainage.
- Score itFeverPAIN or Centor.
- High scorePenicillin V for 5–10 days.
- Grey membrane, unvaccinatedDiphtheria: isolate, antitoxin, antibiotics, notify.
- Teenager with big nodes, tiredness, big spleenGlandular fever: avoid amoxicillin.
- Pain reliefParacetamol or ibuprofen, fluids, salt-water gargles.
- Drooling, stridor, muffled voice, can't swallow fluids
- Quinsy
- Grey membrane (diphtheria)
- Severe dehydration
- Neck swelling or stiff neck (deep neck infection)
- Quinsy
- Epiglottitis
- Diphtheria
- Glandular fever
- Retropharyngeal or parapharyngeal abscess
- Acute HIV
- Cancer (persistent one-sided sore throat in a smoker)
- Rheumatic fever later
| Centor (1 point each) | Fever, tonsillar exudate, tender anterior neck nodes, no cough: 3–4 points, antibiotics |
| FeverPAIN (1 point each) | Fever, Purulence, Attend rapidly (3 days or less), Inflamed tonsils, No cough or cold: 4–5 points, antibiotics |
| Penicillin V | 500 mg 4 times daily (or 1 g twice daily) for 5–10 days |
| Clarithromycin | 250–500 mg twice daily for 5 days if allergic |
| Benzathine penicillin | 1.2 million units IM once (child under 30 kg: 600,000 units) |
| Rheumatic fever | Common in Pakistan: complete the course |
Check every dose against a current drug reference and your hospital protocol.
On this page
Who gets antibiotics?
- No antibiotic
- pain relief
Consider a delayed prescription
Penicillin V for 5–10 days
Most sore throats are viral and last about a week. Antibiotics shorten bacterial tonsillitis by only about a day, but in Pakistan rheumatic heart disease is still common, so treat clearly streptococcal-looking tonsillitis fully, especially in children and young people.
Danger signs
| Condition | Clues | Action |
|---|---|---|
| Quinsy (peritonsillar abscess) | Severe one-sided pain, uvula deviated, trismus, hot potato voice | ENT: aspiration or drainage, IV antibiotics |
| Epiglottitis | Sudden, drooling, sitting forward, stridor, no cough | Don't examine the throat; airway team |
| Diphtheria | Grey membrane, bull neck, unvaccinated | Isolate, antitoxin, antibiotics, notify |
| Retropharyngeal abscess (children) | Neck stiffness, drooling, fever | ENT, imaging |
| Glandular fever | Teenager, big nodes, tiredness, splenomegaly | Supportive; avoid contact sports |
Glandular fever (infectious mononucleosis)
- Teenagers and young adults: severe sore throat, very tired, big lymph nodes, enlarged spleen, palatal petechiae.
- Amoxicillin causes a widespread rash in most patients with EBV. Avoid it if glandular fever is possible.
- Monospot or EBV serology; CBC shows atypical lymphocytes; LFTs often raised.
- Avoid contact sports for 4–8 weeks (spleen rupture risk).
Diphtheria in Pakistan
- Outbreaks occur in under-vaccinated communities.
- Sore throat, low-grade fever, grey adherent membrane that bleeds when scraped, swollen neck ("bull neck").
- Complications: airway obstruction, myocarditis, nerve palsies.
- Isolate, give diphtheria antitoxin early, antibiotics (penicillin or erythromycin), notify public health, protect contacts.
Treatment
Common mistakes
- Antibiotics for every sore throat.
- Amoxicillin for a teenager who might have glandular fever.
- Missing quinsy because nobody looked at the uvula.
- Examining the throat of a child with suspected epiglottitis.
- Missing diphtheria in an unvaccinated child.
- Ignoring a persistent one-sided sore throat in an older smoker.
Frequently asked questions
Does a sore throat need antibiotics?
Most are viral. Antibiotics are given when the FeverPAIN score is 4–5 or Centor 3–4, using penicillin V.
What is quinsy?
A peritonsillar abscess: severe one-sided throat pain, difficulty opening the mouth, a muffled voice and the uvula pushed to the other side. It needs drainage by ENT.
Why avoid amoxicillin in sore throat?
If the cause is glandular fever (EBV), amoxicillin causes a widespread itchy rash in most patients.
How long does a sore throat last?
Most last about a week, whether viral or bacterial.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 19-year-old has fever, tonsillar exudate, tender anterior neck nodes and no cough. What is the Centor score?
Answer: 4. Centor 4: penicillin V for 5–10 days.
- 3: All four present.
- 5: Centor (without age) has four items.
- 2: Count all four.
- 1: Too low.
2. A 25-year-old has one-sided throat pain, trismus and the uvula pushed to the opposite side. What is the diagnosis?
Answer: Quinsy. Peritonsillar abscess needs drainage and antibiotics.
- Tonsillitis only: Uvula deviation suggests abscess.
- Epiglottitis: Different.
- Glandular fever: No deviation.
- Dental abscess: No.
3. A teenager with sore throat develops a widespread rash after amoxicillin. What is the likely underlying diagnosis?
Answer: Glandular fever. EBV infection causes a rash with amoxicillin; avoid it when glandular fever is possible.
- Scarlet fever: Not after amoxicillin.
- Penicillin allergy in all cases: Rash is typical with EBV.
- Kawasaki: No.
- Measles: No.
4. A 19-year-old student has severe sore throat, grey-white tonsillar exudate, palatal petechiae, posterior cervical lymphadenopathy and splenomegaly. She was given amoxicillin and developed a widespread maculopapular rash. What is the underlying diagnosis?
Answer: Infectious mononucleosis (EBV). EBV infectious mononucleosis: fever, exudative tonsillitis, palatal petechiae, posterior cervical/generalised lymphadenopathy, splenomegaly, hepatitis; atypical lymphocytes, heterophile antibody (Monospot) after first week, EBV VCA IgM. Amoxicillin/ampicillin → maculopapular rash in most (not true allergy). Supportive care; steroids if airway compromise; avoid contact sports for ~4 weeks (splenic rupture). Quinsy and airway obstruction are ENT complications.
- Penicillin allergy only: The rash is related to EBV with amoxicillin.
- Streptococcal scarlet fever: Scarlet fever has a sandpaper rash without splenomegaly.
- Diphtheria: Diphtheria has a grey adherent membrane that bleeds.
5. An unvaccinated 6-year-old has sore throat, low-grade fever, a grey adherent tonsillar membrane that bleeds when removed, and a ‘bull neck’. Which complication should be monitored for in the second week?
Answer: Myocarditis. Diphtheria (Corynebacterium diphtheriae exotoxin, inhibits EF-2 via ADP-ribosylation) causes a grey adherent pseudomembrane, cervical lymphadenopathy (bull neck) and toxin-mediated complications: myocarditis (arrhythmias, heart failure — weeks 1–2), neuropathy (palatal palsy, cranial nerves, later peripheral), airway obstruction. Give diphtheria antitoxin early plus penicillin/erythromycin; isolate; ECG monitoring; prophylaxis and vaccination of contacts. Outbreaks occur in Pakistan with low coverage.
- Rheumatic fever: Rheumatic fever follows streptococcal infection.
- Glomerulonephritis: Glomerulonephritis follows streptococcal infection.
- Hepatitis: Hepatitis is not a typical diphtheria complication.
6. Which mechanism explains autoimmune disease after an infection, such as rheumatic fever after streptococcal pharyngitis?
Answer: Molecular mimicry. Molecular mimicry: antibodies or T cells against streptococcal M protein cross-react with cardiac myosin and valve tissue (rheumatic fever); Campylobacter lipooligosaccharide mimics peripheral nerve gangliosides (Guillain–Barré); Coxsackie B and islet antigens (proposed in type 1 diabetes). Normal tolerance mechanisms (deletion, anergy, Tregs) prevent autoimmunity.
- Clonal deletion: Prevents autoimmunity.
- T-cell anergy: Prevents autoimmunity.
- Regulatory T-cell expansion: Prevents autoimmunity.
- Central thymic tolerance: Prevents autoimmunity.
7. Acute rheumatic fever after streptococcal pharyngitis damages the heart through which mechanism?
Answer: Molecular mimicry (M protein). Rheumatic fever follows group A streptococcal pharyngitis (not skin infection) by 2–4 weeks in genetically susceptible children. Immune responses to the bacterial M protein cross-react with cardiac myosin, valve glycoproteins and other self antigens (molecular mimicry), causing pancarditis. Aschoff bodies (with Anitschkow 'caterpillar' cells) are characteristic. Jones criteria: carditis, polyarthritis, chorea (Sydenham), erythema marginatum, subcutaneous nodules, plus evidence of streptococcal infection (ASO titre). Repeated attacks cause chronic rheumatic heart disease, especially mitral stenosis. Secondary prophylaxis with benzathine penicillin prevents recurrences.
- Direct valve invasion: Throat swabs are positive, but valves are not infected.
- Exotoxin poisoning the heart: Not the mechanism.
- Complexes from skin infection: Skin infection causes glomerulonephritis, not rheumatic fever.
- Viral co-infection: Not the cause.
References and dose sources
- NICE NG84 — Sore throat (acute): antimicrobial prescribing
- Phenoxymethylpenicillin (penicillin V) dosing: Drugs.com: Penicillin V potassium dosage (see also our phenoxymethylpenicillin (penicillin v) dose page)
- Clarithromycin dosing: Drugs.com: Clarithromycin dosage (see also our clarithromycin dose page)
- Benzathine penicillin G dosing: Drugs.com: Penicillin G benzathine dosage (see also our benzathine penicillin g dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.