Sore Throat: When It Needs an Antibiotic and When It Does Not
Most sore throats are caused by a virus, need no antibiotic, and get better on their own within about a week. Painkillers, warm fluids and time do almost all of the work. A minority — roughly one adult in ten and rather more children — are caused by the streptococcus bacterium, and those are the ones an antibiotic helps. There is no way to tell reliably by looking in a mirror: white patches on the tonsils occur in both, and so does severe pain. A doctor weighs up fever, swollen tender glands in the neck, pus on the tonsils and the absence of a cough, and may take a throat swab. In Pakistan the threshold for testing or treating is deliberately lower than in Britain or America, because untreated streptococcal throat infection can lead to rheumatic fever and permanent heart valve damage, which remains common here and is now rare there. That is an argument for seeing a doctor when a sore throat comes with fever and no cough — not an argument for buying an antibiotic yourself, which is how resistance is created and how the throat infections that do need treatment become harder to treat. Seek help urgently for difficulty breathing or swallowing saliva, drooling, a muffled voice, a swollen neck, inability to open the mouth, or a sore throat with a high fever in someone taking a medicine that affects the blood count.
Health writers · Aslam Clinic
What a sore throat actually is
The lining of the throat and the tonsils becomes inflamed, usually because an organism has landed on it. makes the tissue red, swollen and painful, and swallowing — which the average person does about six hundred times a day — hurts each time. The tonsils are lumps of immune tissue at the back of the mouth, and part of their job is to meet infections early, which is exactly why they are the first thing to swell.
Around eight out of ten sore throats in adults are viral: the same viruses that cause colds and flu, plus adenovirus, and the Epstein-Barr virus that causes glandular fever. Most of the rest are caused by a called group A streptococcus. A small number have nothing to do with infection at all — burning the throat overnight, allergy and post-nasal drip, dry or smoggy air, shouting, or smoke.
An untreated viral sore throat is at its worst on day two or three and is usually much better by day five to seven; some drag on for ten days, particularly with glandular fever. A streptococcal sore throat treated with an antibiotic improves a little faster, but the difference is smaller than most people expect — on average about a day.
Telling a viral sore throat from a bacterial one
Nobody can do this reliably by looking, including doctors — which is precisely why scoring systems exist. Two are in common use. The Centor criteria award a point each for fever in the illness, tender swollen glands at the front of the neck, pus or white exudate on the tonsils, and the absence of a cough. The FeverPAIN score counts fever in the last day, pus on the tonsils, attending within three days of the symptoms starting, severely inflamed tonsils, and no cough or runny nose. Age matters too: strep throat is much more likely in a school-age child than in an adult over 45, and the McIsaac modification of the Centor score adjusts for exactly that.
| Criteria present | Chance it is streptococcal | What is usually done |
|---|---|---|
| 0 or 1 | Low, around one in twenty | No swab and no antibiotic; painkillers and a review if it worsens |
| 2 | Around one in ten | Usually no antibiotic; a swab if one is available and the illness is severe |
| 3 | Around one in three | Swab where available; many clinicians here treat, especially in a child |
| 4 | Around one in two | Swab and treat, or treat on the clinical picture alone |
A few patterns are worth recognising. A sore throat arriving with a runny nose, a cough and a hoarse voice is almost always viral. Glandular fever should be suspected in a teenager or young adult with a sore throat that has lasted more than a week, very large tonsils, swollen glands at the back of the neck as well as the front, and overwhelming tiredness. It matters because amoxicillin commonly causes a dramatic rash in glandular fever, and because a swollen spleen means avoiding contact sport and heavy lifting for several weeks. Hand, foot and mouth disease in a small child produces painful mouth ulcers with a rash on the palms and soles. And a sore throat that has lasted more than three weeks, particularly with hoarseness, ear pain on one side, a neck lump, or in someone who smokes or uses paan, naswar or gutka, needs examining properly rather than another course of anything.
Why the rules here are not the British rules
British and American guidance treats sore throat as a self-limiting nuisance and sets the bar for prescribing high, because an antibiotic shortens symptoms by roughly sixteen hours and the serious complications it prevents have become vanishingly rare there. That arithmetic depends entirely on the last part of the sentence.
In Pakistan, acute rheumatic fever is not rare. Some weeks after an untreated streptococcal throat infection, the immune response can turn on the body's own tissues, producing fever, painful swollen joints and, most importantly, inflammation of the heart valves. The joints recover; the valves often do not. Rheumatic heart disease remains one of the leading causes of acquired heart disease in young people in this country, and it starts with a sore throat that nobody treated. Post-streptococcal kidney inflammation, which causes blood in the urine and swelling around the eyes, is the other complication seen here more than in Europe.
So a doctor in Lahore may reasonably treat a sore throat that a doctor in London would not. That is a judgement about a population, made after examining a particular throat — and it is an argument for going to a doctor when a sore throat comes with fever and no cough, not an argument for skipping the doctor and buying a course of antibiotics from a shop.
What genuinely helps
- Paracetamol is the mainstay and works well for throat pain. For an adult, 500 mg to 1 g every four to six hours, and never more than 4 g in twenty-four hours from all sources — check that a combination cold remedy does not contain it too. For a child, dose by weight rather than age, using the strength printed on that particular bottle, and follow the pack. Less is used in liver disease and in a very underweight adult.
- An anti-inflammatory painkiller such as ibuprofen, an , relieves throat pain a little better than paracetamol for some people. Avoid it if you have a stomach ulcer or reflux, kidney disease, asthma that flares with these drugs, , or are pregnant, and always take it after food.
- Warm fluids — water, soup, weak tea, yakhni. Frequent small drinks matter more than what is in the cup, and the main purpose is keeping you hydrated while swallowing hurts.
- Honey, alone or in warm water, has modest evidence behind it for throat and cough symptoms. Never give honey to a baby under one year.
- Salt-water gargles — half a teaspoon of salt in a cup of warm water, gargled and spat out. Soothing rather than curative, and not for young children who will swallow it.
- Lozenges or a medicated throat spray numb the throat briefly. Harmless, and no more than that.
- Rest, and stay off work or school while you have a fever. Streptococcal throat stops being infectious about a day after antibiotics are started; a viral one is infectious while symptoms last.
- Stop smoking and shisha entirely while it settles, and keep away from other people's smoke and from dust.
Cold drinks and ice cream do not cause sore throats and do not prolong them; if cold fluids are more comfortable, drink them. The belief that they must be avoided is why some people become dangerously dehydrated while their throat hurts.
The injection question
Being given an injection for a sore throat is common practice here, and it is usually one of two things: an antibiotic, or a corticosteroid such as dexamethasone. Both deserve a straight answer. An injected antibiotic is not stronger or faster than the same drug swallowed, except in someone who genuinely cannot keep tablets down; the injection carries an additional risk of a severe allergic reaction and of abscess at the site, and it is given largely because patients expect it. A single dose of a does modestly reduce throat pain in trials, which is why the habit is entrenched — but the benefit is measured in hours, it does not treat the cause, repeated use carries real harm, and it can mask the fever and swelling of an abscess that needed draining. Neither injection should be the routine answer to a sore throat, and neither is a reason to accept one without an examination.
If antibiotics are prescribed
For streptococcal throat, penicillin V or amoxicillin remains first choice worldwide: the organism has not developed meaningful resistance to it, it is cheap, and it is well studied. Someone with a genuine penicillin allergy is usually given a macrolide instead. The course is longer than the illness — typically ten days for penicillin, which is set by what it takes to prevent rheumatic fever rather than by when the throat stops hurting. That is why finishing it matters here in a way it does not for every infection. Which drug, which dose and how long are a prescriber's decision, made after examining the throat.
Someone who has already had rheumatic fever is a different case entirely: they are usually given long-term penicillin , often as an injection every few weeks for years, to stop a further attack damaging the valves further. That is prescribed and monitored by a doctor, and it should never be stopped because the person feels well.
Sore throats that keep coming back
Recurrent tonsillitis is not the same as a run of colds. Surgery is considered only when the episodes are frequent, severe enough to stop normal life, and — importantly — documented at the time rather than remembered afterwards. The usual thresholds are seven or more episodes in one year, five a year for two consecutive years, or three a year for three consecutive years. Keeping a simple diary of dates, fever and days missed is what turns a vague history into a decision. Tonsillectomy is also considered for a child with breathing pauses in sleep from very large tonsils, and after a second abscess beside the tonsil.
Where the throat is sore most mornings, is worse in dry or smoggy months, or comes with a taste of acid, a hoarse voice and clearing of the throat, look for a cause other than infection: , allergy, mouth breathing from a blocked nose, or air quality. Repeated antibiotic courses for those achieve nothing except .
When to see a doctor
Go to hospital immediately for any of the red flags above. Book an appointment if a sore throat comes with a fever and no cough, if it is severe enough to stop you drinking, if it has not started improving after five days or is still present after a week, if it keeps returning, if it comes with a rash, or if you have diabetes, are pregnant, take a medicine that suppresses immunity, or have had rheumatic fever in the past. See a doctor without delay for any sore throat lasting more than three weeks, especially with hoarseness, a lump in the neck, one-sided ear pain, or in a smoker or paan user. And if you have already bought antibiotics and started them, bring the packet with you rather than hiding it — the doctor needs to know what has been taken.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
