Criteria for antibiotic prescribing in sore throat in primary care?

In primary care, the criteria for prescribing antibiotics for a sore throat are primarily guided by clinical assessment tools such as the FeverPAIN or Centor scores, alongside the patient's overall condition and risk factors ¹.

• Immediate Antibiotic Prescription: An immediate antibiotic prescription should be offered to 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. For individuals with a FeverPAIN score of 4 or 5, or a Centor criteria score of 3 or 4 (or if Group A Streptococcus [GAS] has been confirmed by rapid antigen testing), an immediate antibiotic prescription or a back-up antibiotic prescription should be considered ¹.
• Back-up Antibiotic Prescription: A back-up antibiotic prescription may be considered for those with a FeverPAIN score of 4 or 5, or Centor criteria score of 3 or 4 ¹. It may also be considered for those with a FeverPAIN score of 2 or 3 ¹. A back-up prescription is for use at a later date if symptoms worsen ². Patients should be advised to use the back-up antibiotic if symptoms do not start to improve within 3 to 5 days, or if they worsen rapidly or significantly at any time ¹.
• No Antibiotic Prescription: Do not offer an antibiotic prescription for a FeverPAIN score of 0 or 1, or a Centor score of 0, 1, or 2 ¹. For a FeverPAIN score of 2 or 3, consider no antibiotic prescription, or a back-up antibiotic prescription ¹. This approach considers that antibiotics make little difference to symptom duration (shortening by about 16 hours), most people feel better after 1 week with or without antibiotics, complications are unlikely if antibiotics are withheld, and there are possible adverse effects like diarrhoea and nausea ¹. Do not issue an immediate prescription for an antimicrobial to a patient who is likely to have a self-limiting condition ⁴.
• First-line Antibiotics: Phenoxymethylpenicillin is prescribed first-line ¹. For people with a penicillin allergy, clarithromycin should be prescribed ¹. Erythromycin is preferred for pregnant women with a penicillin allergy ¹.
• Special Considerations: Clinical judgement should be used for vulnerable people (e.g., infants, very old people, those who are immunosuppressed or immunocompromised), as pharyngitis/tonsillitis may run a more severe course ¹. The threshold for treatment or referral for further assessment may be lower for people who are more likely to have a poor outcome, such as those with comorbidities, multimorbidity, or frailty ². If gonococcal or chlamydial infection is confirmed, appropriate treatment should be given ¹. If candidal pharyngitis is suspected, nystatin is prescribed for mild to moderate cases, and fluconazole if the fungal infection is more widespread or symptoms are long-lasting ¹.

All people with acute sore throat should be advised that symptoms may last for around 1 week and to seek medical help if symptoms worsen rapidly or significantly, or they become very unwell ¹. Adequate fluid intake, and the use of ibuprofen and paracetamol for pain and fever, are also recommended ¹.