Best management of patients with an acute sore throat – a critical analysis of current evidence and a consensus of experts from different countries and traditions

Figures & data

Table 1. Probability that a potentially pathogenic bacteria detected in someone with a sore throat is linked to the symptoms.

	Children^a	Adults^a
Group A Streptococcus	65% (42–80%) [19]	92% (87–95%) [19]
Group C Streptococcus	9.2% (0.0–41%) [14]	53% (36–67%) [14]
Streptococcus dysgalactiae subspecies equisimilis^b	68% (0.0–100%) [14]	53% (0.0–92%) [14]
Fusobacterium necrophorum	(No data for children) [20]	64% (33–83%) [21]

^a Children are defined as being below 15–18 years of age (cut-off varies between studies). Percentages provided are etiologic predictive value, with 95% confidence intervals within parenthesis, indicating the probability for a link between the bacterial finding and symptoms while considering the presence of symptomatic carriers ill from something else like a virus [22].

^bStreptococcus dysgalactiae subspecies equisimilis is a new definition of strains including those groups C and G Streptococci now considered to be potential pathogens in humans. Some strains of group C Streptococci that were previously considered potential pathogens in humans are not included in Streptococcus dysgalactiae subspecies equisimilis since their pathogenicity in humans has been reconsidered [14].

Table 2. Scoring algorithms predicting the presence of beta-haemolytic Streptococcus (BHS) in patients with an acute sore throat.

	Centor [28]^a	McIsaac [29]^a	FeverPAIN [17]^a
Timing	–	–	Presentation within 3 days
Signs of viral illness	No cough	No cough	No cough or rhinitis
Fever	History of fever	History of temperature >38 °C	History of fever in the preceding 24 h
Age in years	–	<15: + 1 point >45: − 1 point	–
Presence of swollen tender lymph nodes	Anterior cervical lymph nodes	Anterior cervical lymph nodes	–
Presence of tonsillar exudates	Tonsillar exudates	Tonsillar exudates	Tonsillar exudates
Redness of tonsils	–	–	Severely inflammed pharynx or tonsils
Probability for the presence of bacteria score: probability in %^b	0: 2.5% GAS 1: 6.5% GAS 2: 15% GAS 3: 32% GAS 4: 56% GAS	0: 2.5% GAS 1: 4.4–5.7% GAS 2: 11% GAS 3: 28% GAS 4: 38–63% GAS	0: 14% BHS^c 1: 16% BHS^c 2: 33% BHS^c3: 43% BHS^c4–5: 63% BHS
Maximum score	4	4^d	5

^aThe Centor and McIsaac scores were developed to predict the presence of group A Streptococcus (GAS). The FeverPAIN score was developed to predict the presence of any beta-haemolytic Streptococcus (BHS) of groups A, C and G.

^bThe post-scoring probabilities of finding a bacterium depends on the pre-test probability of this bacterium. Hence, probabilities for finding a bacterium in a certain scoring may vary between different settings. Here we present probabilities for finding a bacterium as presented in the original publications.

^cThe original publication provides figures for any beta-haemolytic Streptococcus (BHS) of group A, C and G Streptococcus combined. Here we present data from the original publication for cohorts 1 and 2 combined.

^dMcIsaac modified the Centor score by age where some ages get an additional score and others get a negative score [29]. McIsaac et al. [29] state ‘Patients with a score lower than 0 were assigned a score of 0, and the highest score allowed was 4’. Hence, age can modify a score within the range of 0–4 but it cannot make the total McIsaac score below 0 or above 4. When McIsaac validated his own score he writes… ‘McIsaac scores of −1 and 5 were normalised to 0 and 4’ [30].

Figure 1. Initial triage of patients in a setting with low risk for rheumatic fever (can be done in a phone or video consultation).

Figure 2. Further assessment and management of patients in a setting with low risk for rheumatic fever (requires a physical visit).

*Some policymakers recommend no antibiotic use, irrespective of the presence of GAS, for patients with an uncomplicated acute sore throat while other policymakers allow a limited use. Policymakers should decide which of these two alternative pathways to recommend in their guidelines.

Table 3. Levels of acute risk for suppurative complications and sepsis in patients attending with a sore throat.

	Apparently uncomplicated	Potentially complicated	Potentially critically ill
History
Impaired immune system	No	Yes
History of peritonsillar abscess	No	Yes
Visits	First visit	Re-visiting health care for the same illness episode
Acute symptoms from the throat
Worsening	No worsening after day 3	Worsening after day 3
Total duration	Duration <5 days OR 5–8 days with noticeable improvement the last 1–2 days	Duration ≥5 days without noticeable improvement OR duration ≥8 days (HIV or mononucleosis?)
Intensity of pain	Mild to moderate intensity or initially severe with very good effect of fast-acting paracetamol	Severe intensity and poor or moderate effect of paracetamol
Location of pain	Mainly bilateral	Unilateral
Acute symptoms from locations other than the throat
Neck stiffness and/or torticollis	No	No	Yes
Swelling of the face or neck	No	No	Yes
Chest pain	No	No	Yes
New altered mental state	No	No	Yes
Passing of urine	Adults: Yes within 12 h	Adults: No urine in 12–17 h	Adults: No urine in ≥18 h
Inability to open the mouth fully	No	Yes
Difficulty swallowing saliva, drooling	No	No	Yes (epiglottitis?)
Severe local pain in the neck, torso or extremities	No	No	Yes (necrotizing fasciitis?)
Abdominal symptoms	No	No	Vomiting OR diarrhoea (toxins?)
Physical examination
General appearance	Mildly but not significantly affected	Significantly affected
Mottled or ashen appearance of skin OR Non-blanching rash	No	No	Yes
Red non-blanching skin rash that has a sandpaper feel or a ‘strawberry tongue’	No	Yes
Rigours (severe shivering)	No	No	Yes
Cyanosis	No	No	Yes on the skin, lips or tongue
Respiratory distress OR stridor	No	No	Yes (epiglottitis)
Very thick, gray membrane covering the throat and tonsils	No	No	Yes (diphtheria?)
Heart rate	Children 3–5 years: <120 Children 6–7 years: <110 Children 8–11 years: <105 All patients ≥12 years: ≤90	Children 3–5 years: 120–129 Children 6–7 years: 110–119 Children 8–11 years: 105–114 All patients ≥12 years: 91–130	Children 3–4 years: sustained >140 Children 5 years: >130 Children 6–7 years: >120 Children 8–11 years: >115 All patients ≥12 years : >130
Systolic blood pressure (mmHg)	All patients ≥12 years: >100	All patients ≥12 years: 91–100	All patients ≥12 years: ≤90 mmHg OR ≥40 mmHg below normal for the patient (if known)
Respiratory rate	Children 3–7 years: <24 Children ≥8 years + adults: <21	Children 3–5 years: 24–28 Children 6–7 years: 24–26 All patients ≥8 years: 21–24	Children 3–5 years: ≥29 Children 6–7 years: >27 All patients ≥8 years: ≥25
Body temperature (tympanic)	≥36 °C AND <39.5 °C	<36 °C OR ≥39.5–41 °C	>41 °C
Oxygen saturation in room air (%)	Children 6–12 years: ≥97% All patients ≥13 years: ≥96%	Children 6–12 years: 95–96% All patients ≥13 years: 92–95%	Children 6–12 years: <95 All patients ≥13 years: <92% (<88% in COPD)

Any single item fulfilled in the rightmost column makes the patient ‘potentially critically ill’ (Inspired by the NICE Sepsis guidelines from 2017). Similarly, any single item fulfilled in the middle orange column rules out that the patient is ‘apparently uncomplicated’. Days below refer to days of illness, not days after contacting health care.

Table 4. Classification of patients attending with an acute sore throat.

	Acute risk for suppurative complications and sepsis
Long-term risk for RHD^a	Apparently uncomplicated	Potentially complicated	Potentially critically ill
Very low (<5/100,000)^b	Low short-term and low long-term risk (most patients in high-income countries)	Moderate short-term and low long-term risk (some patients)	High short-term and low long-term risk (very few patients)
Moderate (5–100/100,000)^b	Low short-term and moderate long-term risk (many patients in low- or middle-income countries)	Moderate short-term and moderate long-term risk (some patients)	High short-term and moderate long-term risk (very few patients)
High (>100/100,000)^b	Low short-term and high long-term risk (most patients in low-income countries)	Moderate short-term and high long-term risk (some patients)	High short-term and high long-term risk (very few patients)

^aRheumatic heart disease.

^bFigures within parentheses are proposed cut-offs for the age-standardised prevalence of rheumatic heart disease per 100,000 population in the country. Local health authorities may want to apply different cut-offs.

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