Comments from Expert Advisory Group
- GPs can use the Respiratory infection information leaflet (including self-care and safety-netting advice) (PDF 488 KB) during consultations with patients presenting with pharyngitis / sore throat / tonsillitis where there is no immediate need for an antibiotic.
- The majority of sore throats are viral in origin. Most patients do not benefit from antibiotics. Consider a delayed antibiotic strategy and explain soreness will take about 7 days to resolve.
- Antibiotics make little difference to how long symptoms last or the number of people whose symptoms improve.
- Withholding antibiotics is unlikely to lead to complications.
- Offer all patients advice about self-care and to seek medical help if symptoms worsen significantly.
- Reassess if symptoms worsen rapidly or significantly, taking account of: alternative diagnoses such as scarlet fever or glandular fever or any symptoms or signs suggesting a more serious illness or condition.
- Consider referral to hospital if they have acute sore throat associated with severe systemic infection or severe suppurative complications (such as abscess).
- If scarlet fever is suspected it is advisable to treat for 10 days duration.
- HPSC update on group A Streptococcus
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FeverPAIN scoring system helps to identify those who are most likely to benefit from antibiotics. This tool has not been assessed in children under 3 years. Each of the FeverPain criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause. FeverPAIN criteria:
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Score 0-1: Do not offer antibiotic Score 2-3: Offer delayed antibiotic Score 4-5: Offer immediate antibiotic prescription |
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A score of 0 or 1 is thought to be associated with a 13% to 18% likelihood of isolating streptococcus. A score of 2 or 3 is thought to be associated with a 34% to 40% likelihood of isolating streptococcus. A score of 4 or 5 is thought to be associated with a 62% to 65% likelihood of isolating streptococcus. |
Symptomatic Relief
- Consider analgesia: paracetamol (or ibuprofen where appropriate).
- Advise patient about adequate intake of fluids.
- Patients report symptom relief from using over-the-counter products such as topical anaesthetic sprays and medicated lozenges containing local anaesthetics.
- Advise to consult pharmacist for symptom relief.
Treatment
| Pharyngitis / Sore Throat / Tonsillitis Antibiotic Treatment Table | |||
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Consider no antibiotic or delayed antibiotic strategy. Score 0-1: Do not offer antibiotic Score 2-3: Offer delayed antibiotic Score 4-5: Offer immediate antibiotic prescription * FeverPAIN tool has not been assessed in children under 3 years |
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| If antibiotics deemed clinically indicated: | |||
| Drug | Dose | Duration | Notes |
| Adults: 1st choice options | |||
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Phenoxymethylpenicillin
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666mg every 6 hours OR 500mg every 6 hours |
5 Days#
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Avoid in penicillin allergy. Recommend to take 30 minutes before a meal or 2 hours after food. |
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#Depending on clinical response, duration can be extended to 10 days in total. If scarlet fever is suspected it is advisable to treat for 10 days duration. |
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| Adults: 2nd choice options | |||
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Amoxicillin |
500mg every 8 hours |
5 days# |
Avoid in penicillin allergy. |
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OR Cefalexin |
500mg every 8 hours |
5 days# |
Cephalosporins should not be used in severe penicillin allergy. |
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OR Clarithromycin
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500mg every 12 hours
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5 days#
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See Macrolide warning and check drug interactions before prescribing. Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy. Alternative macrolide for all trimesters of pregnancy: Azithromycin 500mg stat then 250mg every 24 hours from Day 2 to Day 5. |
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#Depending on clinical response, duration can be extended to 10 days in total. If scarlet fever is suspected it is advisable to treat for 10 days duration. |
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| Children: 1st choice options | |||
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Phenoxymethylpenicillin
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See Phenoxymethylpenicillin dosing for children
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5 days#
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Avoid in penicillin allergy. Recommend to take 30 minutes before a meal or 2 hours after food. |
| Children: 2nd choice options | |||
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Amoxicillin |
5 days# |
Avoid in penicillin allergy. |
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OR Cefalexin |
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5 days# |
Cephalosporins should not be used in severe penicillin allergy. |
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OR Clarithromycin |
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5 days# |
See Macrolide warning and check drug interactions before prescribing. |
| #Depending on clinical response, duration can be extended to 10 days in total. If scarlet fever is suspected it is advisable to treat for 10 days duration. | |||
Patient Information
Safe Prescribing (visit the safe prescribing page)
- Doses are oral and for adults unless otherwise stated
- Dosing in children quick reference dosage/weight guide
- Clarithromycin and other macrolides warning
- Penicillin allergy – tips on prescribing in penicillin allergy
- Renal impairment dosing table
- Safety in Pregnancy and Lactation
- Drug interactions tables. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
- Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).
Reviewed September 2024, minor edit November 2024.