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Acute Infective Sore Throat

This guideline applies to children, young people and adults. 

 

Introduction

This guideline applies to patients with a suspected/confirmed acute infective sore throat. If you suspect a non-infective cause, please follow the  Non-infective Sore Throat guideline.

Symptoms of acute sore throat typically resolve spontaneously within 3 days in 40% and 1 week in 85%, irrespective of whether it is due to a viral or bacterial cause1.

 

Red Flag Features

  • Signs of systemic upset
  • Severe odynophagia resulting in dehydration
  • Peritonsillar abscess (quinsy)
  • Stridor/upper airway obstruction
  • Features of Kawasaki disease

In the presence of an unexplained persistent (more than 4 weeks) sore or painful throat (especially with otalgia) follow the Non-infective Sore Throat guideline.

 

Investigations

No investigations, including throat swabs, are required routinely.

If glandular fever is suspected, it can be useful to check a Serum Monospot Test (over 4 years of age) to confirm the diagnosis. Also consider requesting LFTs and FBC (raised white cell count with lymphocytosis is highly suggestive).

 

Management Optimisation

In context of no red flag features:

  • Reassure usually self-limiting: typically get better within 1 week without antibiotics.
  • Provide patient information and advise self-care.
  • Use a clinical prediction tool to help identify patients who are more likely to benefit from an antibiotic:
    • FeverPAIN
      • Score 0-1: antibiotics not recommended
      • Score 2-3: antibiotics not recommended or deferred prescription
      • Score 4-5: immediate antibiotics, or deferred prescription with advice
    • Centor criteria
      • Score 0-2: antibiotics not recommended
      • Score 3-4: immediate antibiotics, or deferred prescription with advice

A screenshot of a medical chart AI-generated content may be incorrect.

For further information, see:

 

Advice and Guidance

If diagnostic uncertainty, in the absence of red flag features, consider seeking ENT Advice and Guidance.

 

Referral

Emergency assessment:

Call 999 if patient has life-threatening symptoms, such as acute airway obstruction, acute breathing difficulties, impending or suspected sepsis (not an exhaustive list).
 

Same-day assessment:

  • Signs of systemic upset
  • Severe odynophagia resulting in dehydration
  • Peritonsillar abscess (quinsy)
  • Kawasaki disease

*Not an exhaustive list.

In adults, discuss with ENT first on-call to arrange assessment.

In children, discuss with Paediatric first on-call who will liaise with ENT if required.


Routine ENT (Neck and Throat) Referral:

Tonsillectomy for recurrent sore throat is subject to strict commissioning criteria. On the NHS, it is only commissioned when the following criteria are met3:

  • Sore throats are due to acute tonsillitis

AND

  • The episodes are disabling and prevent normal functioning

AND

  • 7 or more, documented, clinically significant, adequately treated sore throats in the preceding year

OR

  • 5 or more such episodes in each of the preceding two years

OR

  • 3 or more such episodes in each of the preceding three years

 

AND

The risks of tonsillectomy versus active monitoring have been discussed with the adult or child and their family or carers, and a shared decision has been made on whether to have the procedure. This discussion should be documented.* 

*The responsibility for full tonsillectomy counselling remains with the responsible surgeon.

 

Referrals that do not clearly evidence how the commissioning criteria are met will be returned.

 

There are a number of medical conditions where episodes of tonsillitis can be damaging to health or tonsillectomy is required as part of the ongoing management. In these instances, tonsillectomy may be considered beneficial at a lower threshold after specialist assessment3:

  • Acute and chronic renal disease due to bacterial tonsillitis
  • Severe guttate psoriasis
  • Metabolic disorders, where reduced oral intake could be harmful to health
  • Periodic Fever, Aphthous stomatitis, Pharyngitis, cervical Adenitis (PFAPA)
  • Severe immunodeficiency
  • 2 or more episodes of quinsy 
  • Children with obstructive sleep apnoea or sleep disordered breathing
  • Suspected malignancy
  • Emergency presentations e.g. treatment of parapharyngeal abscess
  • Tonsillar enlargement causing a previous episode of acute upper airways obstruction or chronic upper airway obstructive symptoms 

In adults (16 and over), send the referral to the Adult ENT (Neck and Throat) Service.

In children (15 and under), send the referral to the Paediatric ENT (Neck and Throat) service.

 

Exclusions:

  • Suspected Obstructive Sleep Apnoea in adults – do NOT refer to ENT; unlike in children, surgical intervention is rarely, if ever, indicated for OSA in adults – refer to Respiratory Sleep Service
  • Tonsillectomy for tonsilloliths (tonsil stones), halitosis and snoring is not routinely commissioned3

 

Supporting Information

For professionals:

 For patients:

 

References

  1. NICE CKS: Acute Sore Throat
  2. NHS Cornwall ICB Treatment Policies
  3. NHS CIOS Commissioning Policies and Evidence-based interventions

 

Page Review Information

Review date

15th May 2025

Next review date

15th May 2026

GP speciality lead

Dr Laura Vines

Contributors

Mr Venkat Reddy, Consultant ENT Surgeon