Reasoning GP · Algorithm · 1-page summary
Sore throat — acute and recurrent
For: adults and children with acute or recurrent sore throat in primary care. Not for: children's antibiotic doses (use BNFC) or hospital management of quinsy, deep-neck infection or Lemierre's syndrome.
Core rule: most sore throats are viral — score FeverPAIN or Centor before any antibiotic. But drooling, a muffled voice or distress is epiglottitis until proven otherwise, even without stridor → 999, keep upright, do not examine the throat.
0Stop — call 999 now — threatened airway or invasive infection
- Suspected epiglottitis/supraglottitis — drooling, muffled voice, severe odynophagia, tripod posture, distress; stridor may be absent → 999
- Stridor, respiratory distress, rapidly progressive neck or floor-of-mouth swelling, severe sepsis; rash with toxicity, meningism, hypotension or non-blanching purpura → 999
- While waiting: keep upright and calm; do NOT lie flat or examine the throat; stay with the patient; oxygen by loose mask if available. Never delay transfer.
1Triage by score — FeverPAIN or Centor (NG84)
| Score | Antibiotic decision |
|---|---|
| FeverPAIN 0–1 · Centor 0–2 | Do not offer an antibiotic; analgesia, fluids, safety-net. |
| FeverPAIN 2–3 | No antibiotic, or a back-up prescription. |
| FeverPAIN 4–5 · Centor 3–4 | Consider an immediate or back-up antibiotic. |
FeverPAIN: Fever ≥38 °C in 24 h · Purulence · Attend ≤3 days · Inflamed tonsils · No cough/coryza. Back-up script: use if not improving in 3–5 days or worse rapidly.
2Screen — one row is enough
- Quinsy — unilateral tonsillar swelling, uvula deviated away, trismus, “hot potato” voice → Same-day ENT.
- Deep-neck infection, unable to swallow fluids, suspected diphtheria (isolate, notify UKHSA) → Same-day ENT / hospital.
- Lemierre's — resolving pharyngitis + rigors, unilateral neck swelling or pleuritic pain → Same-day admission.
- Carbimazole + sore throat, fever or mouth ulcers → stop it, Same-day FBC. Clozapine → immediate FBC via the clozapine team.
- ≥45 with persistent hoarseness; persistent unexplained neck lump; oral ulcer >3 weeks → consider Suspected cancer (NG12). Persistent sore throat or one-sided tonsil → Urgent ENT (local).
- After GAS: carditis, migratory arthritis or chorea; dark urine, oedema or high BP → Same-day assessment.
3Assess — only once blocks 0–2 are answered
☐ Temp, HR, hydration ☐ Voice, drooling, trismus ☐ Tonsils: exudate, asymmetry, uvula, membrane ☐ Nodes: anterior vs posterior ☐ Drugs: carbimazole, clozapine, methotrexate ☐ Sexual history if relevant. No routine throat swab.
4Classify — only if the screen is negative
- Viral pharyngitis (commonest) — coryza, cough, low score → no antibiotic; usually settles within about a week.
- GAS tonsillitis — exudate, fever, tender anterior nodes, no cough; high score → consider antibiotic.
- Scarlet fever — sandpaper rash, strawberry tongue → penicillin 10 days; notify UKHSA; off school until 24 h on antibiotics.
- Glandular fever — young, fatigue, posterior nodes, splenomegaly → consider FBC + EBV serology.
- Gonococcal pharyngitis (relevant sexual history) → urgent GUM referral or discussion. ANUG (gum ulcers, halitosis) → urgent dental referral.
- Uncertain — say so; re-examine rather than repeat antibiotics.
5Treat today — doses: NICE/SPC, BNF, local formulary
- All: paracetamol, or ibuprofen if suitable; fluids. No routine corticosteroids (NG84).
- Antibiotic (adult): phenoxymethylpenicillin 500 mg QDS or 1 g BD for 5–10 days. Penicillin allergy: clarithromycin 250–500 mg BD for 5 days; pregnancy: erythromycin. No amoxicillin if EBV possible.
- Glandular fever: supportive; avoid contact sport, heavy lifting and abdominal-trauma risk for at least 4 weeks from onset.
- No better after 5 days of penicillin: re-examine (EBV? quinsy?); no NG84 second-line — microbiology advice.
6Refer routinely
- Recurrent tonsillitis: ≥7 episodes in 1 year, ≥5/year for 2 years or ≥3/year for 3 years, documented and disabling → ENT. Record each episode.
- Recurrent quinsy (one episode may suffice locally), OSA or significant tonsillar hypertrophy → ENT.
- Confirmed EBV: improves over 2–4 weeks; no fixed review (sooner if worse, jaundice, airway or abdominal pain); nodes >6 weeks → lymphoma exclusion; fatigue >3 months → post-viral assessment.
7Never reassure by
- No stridor — it may be absent in epiglottitis, especially in adults.
- A fairly normal mouth in a patient with drooling, muffled voice or distress.
- Calling it viral in a patient on carbimazole, clozapine or a myelosuppressant without an FBC.
- The sore throat getting better — Lemierre's appears as pharyngitis resolves.
- A negative Monospot in the first week of illness.
- Tonsillar asymmetry “because of the infection” — if it persists after recovery, refer.
8Safety-net — say it, write it, document it
999 “Call 999 if your breathing becomes noisy or difficult, you drool or can't swallow your saliva, you get a stiff neck with a severe headache, a rash that doesn't fade under pressure, or fast-spreading neck swelling.” Same day: “Contact us today if you can't swallow fluids, your voice goes muffled, you can't open your mouth fully, you get neck swelling and pain, or you get rapidly worse — and at once for fever or sore throat on carbimazole or clozapine.”
Review: “It usually lasts about a week. Come back if it is not improving after a week, or for a sore throat or hoarse voice that won't go, one-sided symptoms or a neck lump.”
✓Safe to leave primary care only if — all five, documented
No airway, sepsis or deep-neck feature; epiglottitis not suspected
FeverPAIN or Centor recorded; antibiotic decision matches it
Carbimazole, clozapine and myelosuppressants checked
Persistent or one-sided symptoms, neck lump and hoarseness considered
Written 999 and same-day safety-net and back-up script advice given
Summary of the full Reasoning GP sore throat algorithm, which holds the detail, examination and evidence. Sources: NICE NG84, NICE NG12 (updated April 2026); UKHSA scarlet fever guidance; BASHH gonorrhoea 2025; NHS England EBI / ENT UK tonsillectomy 2021; local antibiotic guide. Follow local pathways. Clinical reference — check doses in the SPC and your local formulary.