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 NICE CKS.

• 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 NICE CKS. 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 NICE CKS.
• 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 NICE CKS. It may also be considered for those with a FeverPAIN score of 2 or 3 NICE CKS. A back-up prescription is for use at a later date if symptoms worsen NICE NG237. 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 NICE CKS.
• 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 NICE CKS. For a FeverPAIN score of 2 or 3, consider no antibiotic prescription, or a back-up antibiotic prescription NICE CKS. 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 NICE CKS. Do not issue an immediate prescription for an antimicrobial to a patient who is likely to have a self-limiting condition NICE NG15.
• First-line Antibiotics: Phenoxymethylpenicillin is prescribed first-line NICE CKS. For people with a penicillin allergy, clarithromycin should be prescribed NICE CKS. Erythromycin is preferred for pregnant women with a penicillin allergy NICE CKS.
• 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 NICE CKS. 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 NICE NG237. If gonococcal or chlamydial infection is confirmed, appropriate treatment should be given NICE CKS. 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 NICE CKS.

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 NICE CKS. Adequate fluid intake, and the use of ibuprofen and paracetamol for pain and fever, are also recommended NICE CKS.