Do I need antibiotics for a sore throat?

Usually not. Most sore throats are caused by viruses and settle within about a week whether or not antibiotics are taken. Group A streptococcus — the bacterium antibiotics target — causes only around 10-15% of adult and 20-30% of childhood sore throats, and across unselected patients antibiotics shorten symptoms by an average of roughly 16 hours. Clinical scores (Centor or FeverPAIN) help estimate the likelihood of bacterial infection based on fever, tonsillar exudate or pus, tender neck glands and the absence of cough. Low scores mean antibiotics are not indicated; higher scores support either a delayed prescription to use if things do not improve, or immediate treatment if the patient is markedly unwell. The important qualification is geographical: in populations with high rates of rheumatic fever, thresholds for treatment are much lower.

What is quinsy and how is it different from tonsillitis?

Quinsy, or peritonsillar abscess, is a collection of pus beside the tonsil rather than infection within it, and it is the commonest deep neck space infection. The features that distinguish it from ordinary tonsillitis are: severe pain concentrated on ONE side; trismus — difficulty opening the mouth, which is the single most useful differentiating sign; a muffled "hot potato" voice; drooling because swallowing is too painful; and, on examination, a bulging soft palate with the uvula pushed away from the affected side. It does not resolve with oral antibiotics alone and requires drainage — either needle aspiration or incision — along with antibiotics and usually corticosteroids. Urgent assessment is needed if there is noisy breathing, inability to swallow saliva, breathlessness or spreading neck swelling.

When should tonsils be removed?

For recurrent infection, the widely used criteria require well-documented, genuinely disabling episodes that prevent normal functioning: seven or more in the preceding year, five or more per year for two years, or three or more per year for three years. Even then, the benefit in adults is real but modest, and many people improve spontaneously — so watchful waiting with a symptom diary is reasonable for borderline cases. The strongest indication for tonsillectomy is not infection at all: it is obstructive sleep-disordered breathing in children, where the tonsils and adenoids are blocking the airway during sleep. Adenotonsillectomy is highly effective for this, and the consequences of leaving it untreated — disturbed sleep, behavioural and attention problems, poor growth and cardiovascular effects — are significant. Other indications include recurrent quinsy and suspected malignancy.

Why does the advice about sore throat differ between countries?

Because the underlying risk differs. In high-income countries with very low rates of acute rheumatic fever, the main reasons to treat streptococcal pharyngitis are modest symptom relief and prevention of local complications such as quinsy — so guidelines emphasise restraint, clinical scoring and delayed prescribing, and often advise against routine testing. In populations where acute rheumatic fever and rheumatic heart disease remain common — including many Indigenous, Pacific Island, sub-Saharan African and South Asian communities — untreated streptococcal pharyngitis can lead to permanent heart valve damage in children, so guidelines recommend routine testing, lower treatment thresholds and full ten-day penicillin courses. The clinical question looks identical; the consequences of getting it wrong are entirely different. This is why guidance cannot simply be copied between settings.

Why should amoxicillin be avoided in sore throat?

Because of glandular fever. If the sore throat is actually infectious mononucleosis caused by Epstein-Barr virus — which is common in adolescents and young adults and closely mimics bacterial tonsillitis, with large exudative tonsils and marked lymphadenopathy — amoxicillin or ampicillin produces a florid, widespread maculopapular rash in the great majority of patients. This rash is not a true allergic reaction, but it is very frequently recorded as one, leaving the patient with an inaccurate lifelong penicillin allergy label that restricts their antibiotic options for decades. Phenoxymethylpenicillin (penicillin V) does not carry the same association and is in any case the correct first-line agent, since group A streptococcus has never developed documented penicillin resistance.

How does GMJ News cover tonsillitis and sore throat?

GMJ News covers the viral predominance of sore throat and antimicrobial stewardship, Centor and FeverPAIN scoring and their limitations, the rheumatic fever context that changes treatment thresholds between settings, penicillin as first-line with no documented resistance, the amoxicillin-EBV rash and spurious allergy labelling, rapid antigen testing and the confounder of streptococcal carriage, quinsy recognition and drainage, Lemierre's syndrome, corticosteroids for symptom relief, tonsillectomy criteria and sleep-disordered breathing as the strongest indication, post-tonsillectomy haemorrhage, and unilateral tonsillar enlargement as a cancer red flag. Directly relevant to PHIG's antimicrobial stewardship, ENT and rheumatic heart disease programmes.

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Tonsillitis and Pharyngitis

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Acute sore throat is among the commonest reasons for primary care consultation worldwide and one of the largest drivers of inappropriate antibiotic prescribing, since the great majority of cases are viral and self-limiting, resolving within a week regardless of treatment, while group A streptococcus accounts for only around 10-15% of adult and 20-30% of paediatric cases (WHO). Clinical scoring systems — Centor and FeverPAIN — were developed precisely to reduce this prescribing, and the pivotal point of context is geographical: in high-income settings the primary rationale for treating streptococcal pharyngitis is modest symptom reduction and prevention of suppurative complications, whereas in populations with high rates of acute rheumatic fever and rheumatic heart disease — including Indigenous, Pacific and many low-income populations — antibiotic treatment of streptococcal pharyngitis remains a genuine public health imperative, a divergence that explains why national guidelines on the same clinical question differ so sharply and why guidance must never be transplanted between settings without this consideration.

Key messages

Most sore throat is viral and self-limiting — a major stewardship target

Acute sore throat is among the commonest reasons for primary care consultation worldwide and one of the largest drivers of inappropriate antibiotic prescribing. Group A streptococcus accounts for only around 10-15% of adult and 20-30% of paediatric cases; the rest are viral (rhinovirus, coronavirus, adenovirus, influenza, EBV). Most sore throats resolve within a week regardless of treatment, and antibiotics shorten symptoms by only around 16 hours on average across unselected patients.

Centor and FeverPAIN scores exist to reduce prescribing, not justify it

Centor criteria (1 point each): tonsillar exudate; tender anterior cervical lymphadenopathy; history of fever; ABSENCE of cough. FeverPAIN (1 point each): Fever in past 24h; Purulence; Attend rapidly (within 3 days); severely Inflamed tonsils; No cough or coryza. Higher scores raise the probability of streptococcal infection but never confirm it — even a maximum score corresponds to only around 50-65% likelihood. Scores of 0-2 make streptococcal infection unlikely and should prompt no antibiotic; higher scores support a delayed prescription or, with marked systemic illness, immediate treatment.

The rheumatic fever context changes the calculus entirely

This is the crucial global-health point. In high-income settings with very low acute rheumatic fever incidence, treating streptococcal pharyngitis is justified mainly by modest symptom reduction and prevention of suppurative complications. In populations with high rates of acute rheumatic fever and rheumatic heart disease — including many Indigenous, Pacific Island, sub-Saharan African, South Asian and other low-income populations — antibiotic treatment of streptococcal pharyngitis is a genuine public health imperative with much lower treatment thresholds and often routine testing. Guidance must never be transplanted between these settings without this consideration.

Penicillin remains first-line — and there is still no documented resistance

Group A streptococcus has never developed documented penicillin resistance, making phenoxymethylpenicillin (penicillin V) the first-line agent worldwide — a 10-day course where the aim is eradication and rheumatic fever prevention, or shorter courses (5 days) where symptom reduction is the aim in low-risk settings. Clarithromycin or erythromycin are the alternatives in penicillin allergy, though macrolide resistance in GAS is significant in many regions. AMOXICILLIN SHOULD BE AVOIDED when infectious mononucleosis is possible — it produces a florid maculopapular rash in the great majority of patients with EBV infection, which is frequently and wrongly recorded as lifelong penicillin allergy.

Quinsy — trismus, uvular deviation and "hot potato" voice

Peritonsillar abscess (quinsy) is the commonest deep neck space infection and a clinical diagnosis: severe unilateral throat pain, trismus (difficulty opening the mouth — the key differentiating sign from simple tonsillitis), a muffled "hot potato" voice, drooling, deviation of the uvula away from the affected side, and a bulging soft palate. Management: needle aspiration or incision and drainage, plus antibiotics and corticosteroids. Escalating features requiring emergency assessment: stridor, inability to swallow saliva, respiratory distress, or spread into the parapharyngeal space with neck swelling and torticollis — the latter raising Lemierre's syndrome (Fusobacterium necrophorum septic thrombophlebitis of the internal jugular vein with septic pulmonary emboli).

Tonsillectomy — clear criteria, and airway obstruction is the strongest indication

For recurrent acute tonsillitis, the widely used SIGN/Paradise criteria require adequately documented, disabling episodes preventing normal functioning: 7 or more in the preceding year, 5 or more per year for 2 years, or 3 or more per year for 3 years. Benefit is real but modest in adults, and most patients improve spontaneously over time — making watchful waiting reasonable for borderline cases. The strongest indication is not infection at all but OBSTRUCTIVE SLEEP-DISORDERED BREATHING in children, where adenotonsillectomy is highly effective and where the consequences of leaving it untreated — behavioural problems, poor growth, cognitive and cardiovascular effects — are substantial. Other indications: recurrent quinsy; suspected malignancy, particularly unilateral tonsillar enlargement in an adult.

Key statistics

10-15% / 20-30%

proportion of adult / paediatric sore throat caused by group A streptococcus

IDSA/NICE

~16 hours

average symptom reduction from antibiotics across unselected sore throat patients

Cochrane

No resistance

group A streptococcus has never developed documented penicillin resistance

IDSA/WHO

Trismus

difficulty opening the mouth is the key sign distinguishing quinsy from simple tonsillitis

ENT UK/AAO-HNS

Avoid amoxicillin

causes a florid rash in most patients with EBV — often misrecorded as penicillin allergy

NICE/BNF

7/5/3 rule

SIGN tonsillectomy criteria: 7 episodes in 1 year, 5/year for 2 years, or 3/year for 3 years

SIGN/ENT UK

Sore throat — probability of streptococcal infection by clinical score

Source: Centor/FeverPAIN validation studies. Even maximum scores do not confirm streptococcal infection.

Glossary of key terms

Rapid antigen detection tests and culture
MicrobiologyRapid antigen detection tests (RADTs) for group A streptococcus give a result in minutes, with high specificity (around 95%) but more variable sensitivity (70-90% depending on test generation and swab technique). Practice differs sharply by setting and reflects the rheumatic fever context: in the United States and in high-rheumatic-fever populations, guidelines recommend testing symptomatic patients and confirming negative RADTs in children with throat culture, because missing a case matters. In much of Europe, including UK NICE guidance, routine testing is not recommended for low-risk populations, because a positive result may reflect carriage rather than infection and testing tends to increase rather than decrease prescribing. Chronic streptococcal carriage — around 10-20% of school-age children — is the fundamental limitation of all testing: a positive test in a child with a viral sore throat is common and misleading.

Complications of streptococcal pharyngitis
ClinicalSuppurative complications, arising from local spread: peritonsillar abscess (quinsy); retropharyngeal and parapharyngeal abscess; cervical lymphadenitis; otitis media; sinusitis; and Lemierre's syndrome. Non-suppurative, immune-mediated complications, arising 1-5 weeks later: acute rheumatic fever (Jones criteria — carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules) leading to rheumatic heart disease, which antibiotic treatment prevents; and post-streptococcal glomerulonephritis (haematuria, oedema, hypertension, low C3), which antibiotic treatment does NOT reliably prevent. Scarlet fever — a streptococcal pharyngitis with a sandpaper rash, strawberry tongue and circumoral pallor — is a notifiable disease in many countries and has shown resurgence in several regions.

Infectious mononucleosis
Infectious diseaseEBV infection classically presents in adolescents and young adults with severe sore throat, marked tonsillar enlargement often with confluent exudate, prominent posterior cervical lymphadenopathy, fever, palatal petechiae, and pronounced, prolonged fatigue; splenomegaly is present in around half. Diagnosis: lymphocytosis with atypical lymphocytes; heterophile antibody (Monospot) test, which has poor sensitivity in young children and in the first week; EBV-specific serology where needed. Critical management points: AVOID amoxicillin and ampicillin, which cause a florid maculopapular rash in the great majority and lead to spurious lifelong penicillin allergy labels; advise avoidance of contact sport and heavy lifting for at least 3-4 weeks because of splenic rupture risk; and reserve corticosteroids for airway compromise from tonsillar hypertrophy rather than routine symptom control.

Post-tonsillectomy haemorrhage
ENT/SurgeryThe principal risk of tonsillectomy and the reason it is not a trivial operation. Primary haemorrhage occurs within 24 hours, usually from inadequate haemostasis, and requires immediate return to theatre. Secondary haemorrhage occurs typically 5-10 days postoperatively as the fibrin slough separates, is often associated with infection and dehydration, and affects a few per cent of patients. Any post-tonsillectomy bleeding — including a small amount of blood-stained saliva — requires urgent hospital assessment, since a small herald bleed may precede a major one. Management: resuscitation, IV access and fluids, group and save, antibiotics, and either conservative management with close observation or return to theatre. Good analgesia and hydration in the first two weeks reduce secondary haemorrhage, and inadequate postoperative analgesia is a common and avoidable contributor.

Corticosteroids in acute sore throat
Evidence/TherapeuticsA single dose of oral dexamethasone (typically around 10mg in adults) roughly doubles the likelihood of complete symptom resolution at 24 hours in patients with severe sore throat, and reduces time to onset of pain relief, according to a Cochrane review and the UK TOAST randomised trial. This effect is independent of whether antibiotics are given. Practically, corticosteroids offer a way of achieving meaningful symptom relief in severely symptomatic patients without prescribing an antibiotic — clinically useful in a stewardship context. They should not be used routinely for mild sore throat, and caution applies in diabetes, immunosuppression and where a deep neck space infection or EBV airway compromise needs specialist assessment rather than symptomatic treatment.

Unilateral tonsillar enlargement in adults
ENT/OncologyA persistently enlarged single tonsil in an adult — particularly with ulceration, induration, unexplained cervical lymphadenopathy, weight loss, referred otalgia or a smoking and alcohol history — is a red flag requiring urgent ENT referral. Differential: squamous cell carcinoma of the tonsil, now increasingly HPV-related and occurring in younger, non-smoking patients where the primary tumour may be small and the presenting feature is a neck node; lymphoma; and, less commonly, atypical infection. Asymmetry alone is common and often benign — tonsils frequently differ in apparent size because of variable depth within the fossa — but true unilateral enlargement with any additional feature should never be observed indefinitely without specialist assessment and, where indicated, diagnostic tonsillectomy.

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Tonsillitis and Pharyngitis

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