Sore Throat

Last updated 1 Jun 2026 · General Practice / ENT

📋 Key Information Summary

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Most sore throats are viral — only 10–15% of adult and 20–30% of paediatric presentations are caused by Group A Streptococcus (GAS); antibiotics are not required for the majority of cases.
Use the McIsaac / Centor clinical prediction score to stratify the likelihood of GAS pharyngitis and guide the decision to test or treat empirically (≥3 points warrants testing).
Rapid antigen detection testing (RADT) is the preferred point-of-care investigation in Australian general practice; throat culture is reserved for negative RADT in high-risk patients or public health outbreaks.
Phenoxymethylpenicillin (Penicillin V) remains first-line for confirmed GAS pharyngitis — 500 mg PO BD for adults (50 mg/kg/day in children) for 10 days. It is PBS-listed as a General Benefit.
Amoxicillin is an acceptable alternative first-line agent with better palatability in children; 500 mg PO TDS (adults) or 45 mg/kg/day in two divided doses (children) for 10 days.
Penicillin-allergic patients should receive a narrow-spectrum cephalosporin (if low-risk allergy) or azithromycin / clarithromycin (if anaphylaxis risk). Roxithromycin is an alternative in Australia.
Epstein-Barr virus (EBV) mononucleosis should be suspected in adolescents and young adults with fever, pharyngitis, lymphadenopathy, and fatigue — a Monospot (heterophile antibody) test or EBV serology confirms diagnosis. Avoid amoxicillin/ampicillin which causes a characteristic maculopapular rash in ~70–100% of EBV cases.
Peritonsillar abscess (quinsy) is a medical emergency requiring urgent drainage (needle aspiration or incision), IV antibiotics, and ENT referral. It presents with trismus, "hot potato" voice, and unilateral palatal swelling.
Recurrent tonsillitis — consider ENT referral for tonsillectomy when episodes meet Paradise criteria (≥7 episodes in 1 year, ≥5/year for 2 years, or ≥3/year for 3 years).
Supportive care is the mainstay for viral pharyngitis: paracetamol or ibuprofen for analgesia, adequate hydration, salt-water gargles, and rest. Short-course corticosteroids may be considered for severe odynophagia.
Rheumatic fever prevention — in Aboriginal and Torres Strait Islander populations and other at-risk groups, a positive GAS result mandates a full 10-day antibiotic course (or intramuscular benzathine penicillin) to prevent acute rheumatic fever and rheumatic heart disease.
Red flags requiring emergency assessment: stridor, drooling/inability to swallow, respiratory distress, suspected epiglottitis, lateral pharyngeal space abscess, or meningism — these require immediate hospital referral.

Introduction & Australian Epidemiology

Acute pharyngitis and tonsillitis (commonly referred to as "sore throat") are among the most frequent presentations in Australian general practice, accounting for an estimated 2–3% of all GP encounters annually. The vast majority are self-limiting viral infections; however, the minority caused by Group A Streptococcus (GAS) carry a small but significant risk of suppurative complications (peritonsillar abscess, retropharyngeal abscess) and non-suppurative sequelae, most importantly acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis.

Australian burden of disease: The Royal Australian College of General Practitioners (RACGP) and the Australian Commission on Safety and Quality in Health Care (ACSQHC) have identified acute pharyngitis as a key target for antimicrobial stewardship. National Prescribing Service (NPS MedicineWise) data indicate that antibiotics are prescribed for approximately 60–80% of sore throat presentations in Australia, far exceeding the proportion of confirmed bacterial infections — highlighting significant overprescribing.

Acute rheumatic fever (ARF) in Australia: ARF remains a critical concern in Aboriginal and Torres Strait Islander communities, particularly in remote and very remote areas of the Northern Territory, Queensland, and Western Australia. The incidence of first-episode ARF in Indigenous Australians is 60–120 per 100,000 in high-endemic regions, compared with <1 per 100,000 in non-Indigenous populations. GAS pharyngitis management in these communities has direct public health implications under the Rheumatic Fever Strategy and RHDAustralia clinical guidelines.

Antimicrobial resistance considerations: Australian surveillance (Australian Group on Antimicrobial Resistance — AGAR) confirms that GAS isolates remain universally susceptible to penicillin. However, macrolide resistance (erythromycin, azithromycin) has been reported in 5–10% of Australian GAS isolates, reinforcing the recommendation that penicillin remains first-line therapy. CA-MRSA (community-associated methicillin-resistant Staphylococcus aureus) is relevant in suppurative complications but not in uncomplicated GAS pharyngitis.

Sore Throat Diagnostic Model

The clinical challenge in sore throat management is distinguishing self-limiting viral pharyngitis from GAS pharyngitis that warrants antibiotic therapy, while avoiding both overprescribing and missed suppurative or non-suppurative complications. The recommended diagnostic approach in Australian general practice integrates clinical scoring, point-of-care testing, and safety-netting.

McIsaac / Centor Clinical Prediction Score

The modified Centor score (McIsaac criteria) is the most widely validated clinical prediction rule for GAS pharyngitis. It stratifies patients into risk categories to guide the decision to test and/or treat.

Criterion	Points
Age 3–14 years	+1
Age ≥45 years	−1
Tonsillar exudate or swelling	+1
Tender anterior cervical lymphadenopathy	+1
Fever (>38°C) by history or measurement	+1
Absence of cough	+1

Low risk

Score ≤0

GAS probability <5%. No antibiotic or RADT required. Supportive care and safety-netting advice.

Setting: GP — reassurance and self-care

Moderate risk

Score 1–2

GAS probability 5–17%. Perform RADT if available; treat only if RADT positive. If RADT unavailable, observe with safety-netting.

Setting: GP — RADT-guided management

High risk

Score ≥3

GAS probability 25–50%. RADT recommended; if RADT unavailable, consider empirical treatment and send throat culture. In high ARF-risk populations, empirical treatment pending culture is justified.

Setting: GP — test-and-treat or empirical therapy

Clinical Features Suggesting Viral Aetiology

Coryza (rhinorrhoea, nasal congestion)
Cough
Conjunctivitis
Hoarseness / laryngitis
Diarrhoea or other gastrointestinal symptoms
Vesicles or ulcers on the palate or oropharynx (coxsackievirus — herpangina)
Gradual onset, low-grade fever

Red Flags Requiring Urgent Assessment

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Stridor or respiratory distress — suspect epiglottitis, croup, or retropharyngeal abscess; call 000
Inability to swallow saliva / drooling — potential airway compromise
Trismus with unilateral palatal swelling — peritonsillar abscess (quinsy)
Rapidly progressive unilateral swelling — lateral pharyngeal space or parapharyngeal abscess
Meningism with pharyngitis — consider meningococcal disease
Immunocompromised patient with severe pharyngitis — broader differential, lower threshold for investigation

Stepwise Diagnostic Approach

History & Examination

Assess onset, severity, associated symptoms, comorbidities, and risk factors. Examine oropharynx, neck, and ears.

Calculate McIsaac Score

Apply age, fever, tonsillar signs, lymphadenopathy, and cough status to stratify risk.

Perform RADT (if score ≥1)

Point-of-care RADT has specificity >95% but sensitivity 70–90%. A positive result confirms GAS; a negative result in high-risk patients warrants throat culture.

Treat or Safety-Net

Positive RADT → antibiotics. Negative RADT with low score → supportive care. High-risk and RADT-negative → send culture, consider empirical therapy in ARF-endemic populations.

Bacterial Causes & Streptococcal Guidelines

While viruses account for the majority of pharyngitis cases, several bacterial pathogens warrant consideration. Group A Streptococcus (Streptococcus pyogenes) is the most important bacterial cause due to the risk of acute rheumatic fever and suppurative complications.

Bacterial Pathogens in Pharyngitis

Organism	Prevalence	Key Features	Notes
Streptococcus pyogenes (GAS)	10–15% adults; 20–30% children	Sudden onset, fever, tonsillar exudate, tender anterior cervical nodes, absence of cough	Most important — risk of ARF, PSGN, peritonsillar abscess
Group C & G Streptococci	5–10%	Clinically indistinguishable from GAS	Not associated with ARF; treatment debated but generally treated in symptomatic patients
Fusobacterium necrophorum	10–20% (young adults)	Pharyngitis with potential for Lemierre syndrome (internal jugular vein septic thrombophlebitis)	Responsive to penicillin; consider in persistent pharyngitis in 15–30-year age group
Arcanobacterium haemolyticum	1–2.5%	Pharyngitis + scarlatiniform rash in adolescents/young adults	Treat with erythromycin or penicillin
Mycoplasma pneumoniae	Variable	Pharyngitis + lower respiratory symptoms	Macrolide or doxycycline if symptomatic
Chlamydophila pneumoniae	Variable	Hoarseness, prolonged course	Macrolide or doxycycline

Rapid Antigen Detection Testing (RADT)

RADT detects GAS carbohydrate antigen from a throat swab with results available in 5–10 minutes. In Australian general practice:

Sensitivity: 70–90% (varies by kit; generally lower in adults)
Specificity: >95%
Clinical implication: A positive RADT confirms GAS and warrants treatment. A negative RADT in a high-risk patient (score ≥3) should be followed by throat culture (sensitivity >90%).
Asymptomatic carriers: RADT may be positive in 5–15% of asymptomatic children (pharyngeal carriage). Do not treat asymptomatic carriers unless there is a specific epidemiological indication (e.g., outbreak in closed community, post-ARF prophylaxis consideration).

Antibiotic Treatment of GAS Pharyngitis

The goals of antibiotic therapy for GAS pharyngitis are: (1) to reduce symptom duration and severity, (2) to prevent suppurative complications (peritonsillar abscess, cervical lymphadenitis), (3) to prevent acute rheumatic fever, and (4) to reduce transmission. GAS remains universally penicillin-susceptible in Australia.

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Phenoxymethylpenicillin (Penicillin V)

Cilicaine VK® · Generic · Narrow-spectrum penicillin

Adult dose 500 mg PO BD (or 250 mg QID) for 10 days

Paediatric dose Child >20 kg: 250 mg PO BD–TDS for 10 days; Child ≤20 kg: 125 mg PO BD–TDS for 10 days (total ~25–50 mg/kg/day in 2–3 divided doses)

Route Oral

Duration 10 days (mandatory for ARF prevention)

Renal adjustment No adjustment required

Hepatic adjustment No adjustment required

PBS status ✔ PBS General Benefit

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Amoxicillin

Amoxil® · Generic · Aminopenicillin

Adult dose 500 mg PO TDS (or 1 g PO BD) for 10 days

Paediatric dose 45 mg/kg/day in 2 divided doses (BD) for 10 days; max 1 g/dose

Route Oral

Duration 10 days

Renal adjustment eGFR <30 mL/min: reduce dose or extend interval

Hepatic adjustment No adjustment required

PBS status ✔ PBS General Benefit

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Benzathine Penicillin G (IM)

Bicillin L-A® · Long-acting penicillin

Adult dose 900 mg (1.2 MU) IM single dose

Paediatric dose <27 kg: 450 mg (0.6 MU) IM single dose; ≥27 kg: 900 mg (1.2 MU) IM single dose

Route Intramuscular

Duration Single dose — preferred in ARF-endemic settings and when oral adherence is uncertain

Renal adjustment No adjustment required

PBS status ✔ PBS General Benefit

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Azithromycin

Zithromax® · Generic · Macrolide

Adult dose 500 mg PO on Day 1, then 250 mg PO daily on Days 2–5 (total 1.5 g over 5 days)

Paediatric dose 12 mg/kg/day PO for 5 days; max 500 mg Day 1 then 250 mg Days 2–5

Route Oral

Duration 5 days

Renal adjustment eGFR <10 mL/min: use with caution

Note Reserved for penicillin allergy (IgE-mediated/anaphylaxis). Macrolide resistance in GAS 5–10% in Australia. Monitor for GI side effects.

PBS status ✔ PBS General Benefit

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Roxithromycin

Rulide® · Generic · Macrolide

Adult dose 300 mg PO daily (or 150 mg PO BD) for 10 days

Paediatric dose Children <40 kg: 5 mg/kg PO BD for 10 days; ≥40 kg: adult dose

Route Oral

Duration 10 days

Renal adjustment No adjustment required

PBS status ✔ PBS General Benefit

⚠️

Complete the full 10-day course. Although symptoms typically resolve within 3–5 days, abbreviated courses are associated with bacteriological failure and do not reliably prevent acute rheumatic fever. In ARF-endemic communities, intramuscular benzathine penicillin (single injection) ensures adherence and is the preferred option.

Antibiotic Choice by Allergy Status

Allergy Scenario	Recommended Agent	Notes
No penicillin allergy	Phenoxymethylpenicillin (or amoxicillin)	First-line — 10 days
Non-anaphylactic penicillin allergy (mild rash only)	Cefalexin 500 mg PO BD–TDS for 10 days	Cross-reactivity risk <2% with 3rd-gen cephalosporins; 1st-gen ~1–2% if mild allergy
IgE-mediated / anaphylaxis to penicillin	Azithromycin (5-day course) or roxithromycin (10-day course)	Avoid cephalosporins; consider clindamycin if macrolide resistance suspected
Macrolide-resistant GAS suspected	Clindamycin 450 mg PO TDS for 10 days	Consult infectious disease specialist; obtain susceptibility testing

Epstein-Barr Mononucleosis Screening

Infectious mononucleosis (IM), caused by Epstein-Barr virus (EBV), is a common cause of pharyngitis in adolescents and young adults (peak age 15–24 years). It should be considered in any patient with pharyngitis that fails to improve after 7–10 days, or when accompanied by prominent systemic features.

Clinical Features

Classic triad: fever, pharyngitis (often severe with tonsillar exudate), and lymphadenopathy (especially posterior cervical)
Splenomegaly: Present in ~50% of cases — clinically palpable in ~15%
Profound fatigue: May persist for weeks to months
Hepatomegaly / hepatitis: Mild transaminitis in 80–90%
Periorbital oedema (Hoagland sign): Present in ~30% early in illness
Maculopapular rash following amoxicillin or ampicillin administration (occurs in 70–100% of EBV patients given aminopenicillins)

Diagnostic Approach

Essential

Full Blood Count (FBC) with Differential

Atypical lymphocytosis (≥10% atypical lymphocytes or ≥4.5 × 10⁹/L total lymphocytes with ≥10% atypical forms) is highly suggestive. FBC is Medicare-rebatable (MBS Item 66515).

Available

Monospot Test (Heterophile Antibody / Paul-Bunnell)

Rapid agglutination test. Sensitivity 85% in adults, but only 25–50% in children <12 years. False negatives common in the first week. A positive Monospot with compatible clinical picture is diagnostic. Available in most Australian pathology services.

Available

EBV-Specific Serology (VCA IgG/IgM, EBNA, EA)

More sensitive and specific than Monospot. VCA IgM positive + EBNA negative = acute infection. Required when Monospot is negative but clinical suspicion remains high. MBS-rebatable through major pathology providers (Sonic, Healius, etc.).

Referral

Liver Function Tests (LFTs)

Mild transaminitis (ALT/AST 2–3× upper limit of normal) is expected. Severe hepatitis warrants hepatology input.

Referral

Ultrasound — Abdomen

Not routine but indicated if splenic enlargement is suspected clinically or to assess for splenic rupture (rare but life-threatening).

⚠️

AVOID amoxicillin and ampicillin in suspected EBV mononucleosis. These agents cause a widespread maculopapular rash in 70–100% of patients with acute EBV infection, which is often misdiagnosed as a drug allergy. This reaction is thought to be a non-allergic, cell-mediated immune phenomenon rather than true hypersensitivity.

Management of EBV Mononucleosis

No antiviral therapy is recommended for uncomplicated IM (acyclovir/valacyclovir do not improve outcomes)
Supportive care: paracetamol for fever and pain, adequate hydration, rest
Avoid contact sports and strenuous activity for at least 3–4 weeks (splenic rupture risk) — longer if splenomegaly documented on imaging
Corticosteroids — reserved for complications: impending airway obstruction, severe haemolytic anaemia, myocarditis, or meningoencephalitis. Prednisolone 40–50 mg PO daily for 5–7 days with taper.
Most patients recover fully within 2–4 weeks; fatigue may persist for 2–3 months in 10–20%

Complications

Complication	Incidence	Management
Splenic rupture	0.1–0.5%	Surgical emergency; may be managed conservatively if haemodynamically stable
Airway obstruction (tonsillar hypertrophy)	<1%	Corticosteroids ± urgent tonsillectomy; consider ICU admission
Autoimmune haemolytic anaemia	2–5% (cold agglutinin mediated)	Corticosteroids; transfusion if severe
Thrombocytopenia	25–50% (usually mild)	Monitoring; treatment only if severe/bleeding
Hepatitis	80–90% (subclinical)	Self-limiting; avoid hepatotoxins
Neurological (GBS, facial nerve palsy, meningoencephalitis)	<1%	Specialist referral and management

Recurrent Tonsillitis & Peritonsillar Abscess

Recurrent Tonsillitis

Recurrent acute tonsillitis is defined as repeated episodes of acute tonsillitis that significantly affect quality of life, school or work attendance, and healthcare utilisation. The decision to refer for tonsillectomy should be based on established criteria and shared decision-making with the patient (or parents/caregivers for children).

Paradise Criteria for Tonsillectomy

The Paradise criteria, originally developed for children but applied across age groups in Australian practice, provide evidence-based thresholds for surgical referral:

Criterion	Threshold
Option A — Frequency threshold	≥7 episodes of sore throat in the preceding 1 year
Option B	≥5 episodes per year in each of the preceding 2 years
Option C	≥3 episodes per year in each of the preceding 3 years

Each qualifying episode should include at least one of: temperature >38.3°C, tonsillar exudate, positive GAS swab, or tender anterior cervical lymphadenopathy.

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Modified criteria (Scottish Intercollegiate Guidelines Network — SIGN): In practice, some Australian ENT surgeons apply modified criteria, accepting a lower threshold (e.g., 5 episodes/year for 1 year) when episodes are severe, require hospitalisation, or are associated with significant complications. Clinical judgement and patient preference should guide referral decisions.

When to Refer for ENT Assessment

Meeting Paradise (or modified) frequency criteria
Peritonsillar abscess (quinsy) — even after successful drainage, consider elective tonsillectomy after resolution
Tonsillar hypertrophy causing obstructive sleep apnoea (OSA) — especially in children
Suspected tonsillar malignancy (unilateral tonsil enlargement, especially in adults >40 years with risk factors — smoking, alcohol) — urgent referral
PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) in children — recurrent episodes at regular intervals

Peritonsillar Abscess (Quinsy)

Peritonsillar abscess (PTA) is the most common deep space infection of the head and neck, typically arising as a complication of acute tonsillitis. It occurs when infection extends through the tonsillar capsule into the peritonsillar space. Peak incidence is in young adults (20–40 years), with a slight male predominance.

Clinical Presentation

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Severe, progressive unilateral sore throat — often with referred otalgia (ear pain on the affected side)
Trismus — difficulty opening the mouth (reduced inter-incisor distance <30 mm) due to inflammation of the internal pterygoid muscle
"Hot potato" voice — muffled, dysarthric speech
Drooling — inability to swallow secretions
Unilateral palatal and tonsillar swelling — uvula displaced contralaterally; soft palate bulge
Fever, malaise, and dehydration
Cervical lymphadenopathy — typically jugulodigastric node

Diagnosis

Clinical diagnosis is usually sufficient in the classic presentation (unilateral swelling, trismus, uvular deviation)
Intraoral ultrasound (if available) — sensitivity 89–95%, specificity 79–100% — can differentiate cellulitis from abscess and guide aspiration. Increasingly available in Australian EDs with point-of-care ultrasound capability
CT neck with contrast — if diagnosis uncertain, or to assess for extension into the parapharyngeal or retropharyngeal space, mediastinum, or to rule out Lemierre syndrome. Available in all Australian hospital radiology departments.
Needle aspiration — serves both diagnostic (pus obtained confirms abscess) and therapeutic purposes

Management

Drainage

Needle aspiration (first-line in most Australian EDs) — 18G needle, aspirate through the point of maximal convexity of the palatal bulge. Success rate 85–90%. May require repeat aspiration in 24–48 hours. Incision and drainage — alternative if needle aspiration fails or abscess is large. Both procedures require adequate local anaesthesia and suction equipment. Must be performed by experienced clinician (ED physician or ENT registrar).

IV Antibiotics

First-line: Amoxicillin 1 g IV TDS + metronidazole 500 mg IV TDS (to cover anaerobes including Fusobacterium). Penicillin allergy: Clindamycin 600 mg IV TDS (covers GAS and anaerobes). Duration: IV for 24–48 hours until clinically improving, then switch to oral to complete 10–14 days total.

Supportive Care

IV fluid rehydration, adequate analgesia (IV paracetamol ± IV NSAIDs ± opioids for severe pain), antiemetics if required. Monitor for airway compromise.

ENT Referral & Disposition

All PTA patients should be seen by ENT. Most require admission for 24–48 hours. Arrange ENT follow-up within 1–2 weeks. Discuss interval tonsillectomy (quinsy tonsillectomy) — recurrence rate 10–15% without tonsillectomy.

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Amoxicillin (IV)

Generic · Aminopenicillin

Adult dose 1 g IV TDS (for peritonsillar abscess)

Duration IV 24–48 hours, then oral step-down to complete 10–14 days total

PBS status ✔ PBS General Benefit (hospital authority)

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Metronidazole

Flagyl® · Generic · Nitroimidazole

Adult dose 500 mg IV TDS (or 400 mg PO TDS for oral step-down)

Paediatric dose 7.5 mg/kg IV/PO TDS (max 500 mg)

Duration 7–10 days (as part of PTA regimen)

Renal adjustment No adjustment required for short courses

PBS status ✔ PBS General Benefit

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Clindamycin

Dalacin C® · Generic · Lincosamide

Adult dose 600 mg IV TDS (or 450 mg PO QID for oral step-down)

Paediatric dose 10 mg/kg IV TDS (max 600 mg); 10 mg/kg PO TDS (max 450 mg)

Duration 10–14 days

Renal adjustment No adjustment required

Note Monitor for Clostridioides difficile infection. Avoid in patients with history of C. diff colitis.

PBS status ✔ PBS General Benefit

Differential Diagnosis — Unilateral Sore Throat

Condition	Distinguishing Features
Peritonsillar abscess (quinsy)	Trismus, "hot potato" voice, unilateral palatal bulge, uvular deviation
Parapharyngeal abscess	Lateral neck swelling, torticollis, may compromise airway — CT required
Retropharyngeal abscess	Neck stiffness, odynophagia, bulging posterior pharyngeal wall — CT required
Lemierre syndrome	Pharyngitis + internal jugular vein septic thrombophlebitis + septic pulmonary emboli. Caused by F. necrophorum. CT neck with contrast; blood cultures often positive.
Eagle syndrome	Elongated styloid process or calcified stylohyoid ligament — chronic unilateral throat pain; diagnosed on CT
Tonsillar malignancy	Unilateral tonsil enlargement in adult >40 years, ± weight loss, ± cervical lymphadenopathy — urgent ENT biopsy

Special Populations

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Pregnancy

Phenoxymethylpenicillin / Amoxicillin

Safe in pregnancy (Category A). First-line for GAS pharyngitis. Complete 10-day course to prevent ARF risk — critical if patient is in ARF-endemic region.

Roxithromycin / Azithromycin

Category B1 — preferred macrolide in pregnancy for penicillin-allergic patients. Erythromycin estolate is contraindicated (hepatotoxicity risk in pregnancy).

Avoid: Tetracyclines (doxycycline), fluoroquinolones

Category D. Avoid throughout pregnancy and breastfeeding.

Paracetamol for analgesia

First-line analgesic/antipyretic in pregnancy. Avoid ibuprofen, especially in the third trimester (risk of premature closure of ductus arteriosus).

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Paediatrics

GAS pharyngitis is uncommon <3 years

Pharyngitis in children <3 years is almost always viral. GAS carriage is common; do not routinely swab or treat unless there is a clear clinical indication or outbreak setting.

Amoxicillin suspension (preferred for palatability)

45 mg/kg/day PO in 2 divided doses for 10 days. Better taste than phenoxymethylpenicillin suspension, improving adherence. Use weight-based dosing charts.

Benzathine penicillin IM (ARF prevention)

In ARF-endemic communities, single IM injection is preferred to ensure completion of therapy. <27 kg: 450 mg (0.6 MU); ≥27 kg: 900 mg (1.2 MU).

Monospot sensitivity is low (25–50%) in children <12 years

EBV serology is preferred when mononucleosis is suspected in children. Atypical lymphocytes on FBC are a helpful screening finding.

PFAPA syndrome

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis — regular episodic fevers every 3–8 weeks in young children. Tonsillectomy is curative in most cases. Short-course corticosteroids (prednisolone 1–2 mg/kg) abort individual episodes.

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Elderly

GAS pharyngitis is uncommon >45 years

The McIsaac score assigns −1 point for age ≥45 years, reflecting lower prevalence. A negative RADT in this age group has a high negative predictive value.

Consider alternative diagnoses

Unilateral sore throat in an older adult raises concern for tonsillar or oropharyngeal malignancy (especially if smoking/alcohol history), Eagle syndrome, or referred cardiac pain. Low threshold for ENT referral and further investigation.

Renal dose adjustment

Adjust amoxicillin and other renally cleared antibiotics according to eGFR. Phenoxymethylpenicillin does not require adjustment.

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Renal Impairment

Phenoxymethylpenicillin

No dose adjustment required — drug of choice in renal impairment.

Amoxicillin

eGFR 10–30 mL/min: reduce dose or extend interval. eGFR <10 mL/min: 250 mg PO TDS or 500 mg PO BD (or consider phenoxymethylpenicillin instead).

Azithromycin

No dose adjustment for renal impairment, but use with caution if eGFR <10 mL/min.

Metronidazole

Not significantly renally cleared; no adjustment for short courses. Accumulates with prolonged use — reduce dose if prolonged therapy needed.

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Hepatic Impairment

Phenoxymethylpenicillin / Amoxicillin

No dose adjustment required. Safe in hepatic impairment.

Metronidazole

Metabolised hepatically — use with caution in severe hepatic impairment. Reduce dose if significant liver disease. Monitor LFTs if prolonged use.

Clindamycin

Metabolised hepatically — dose reduction may be needed in severe hepatic failure. Monitor LFTs.

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Immunocompromised

Broader differential

Consider opportunistic infections: CMV pharyngitis, oral candidiasis, HSV esophagitis, mucositis (in chemotherapy patients). Lower threshold for investigation — FBC, blood cultures, viral PCR, and specialist referral.

Lower threshold for empirical antibiotics

Immunocompromised patients with pharyngitis and systemic illness (fever, neutropenia) should receive empirical broad-spectrum antibiotics per local neutropenic fever protocols. Refer to infectious disease or haematology guidelines.

HIV-positive patients

Acute retroviral syndrome (primary HIV infection) may present with pharyngitis, fever, lymphadenopathy, and rash. Consider HIV testing in at-risk individuals with compatible presentation. Oral candidiasis (thrush) is common with advanced immunosuppression.

Investigations

Investigation strategy depends on the clinical context, McIsaac score, and suspected aetiology. Most patients with low McIsaac scores (≤0) and viral features require no investigations.

Essential

Throat Swab — RADT (Point-of-Care)

For GAS antigen detection. Perform in patients with McIsaac score ≥1. Available in most Australian GP practices (CLIA-waived kits). Sensitivity 70–90%, specificity >95%. Results in 5–10 minutes. MBS: not separately billable (included in consultation).

Available

Throat Swab — Culture (GAS)

Gold standard for GAS detection (sensitivity >90%). Send when RADT is negative in a high-risk patient (McIsaac ≥3). Results in 24–48 hours. Also useful for antibiotic susceptibility if macrolide resistance suspected. MBS Item 69310 (microbiological investigation).

Available

Full Blood Count (FBC)

Suspected EBV mononucleosis — look for atypical lymphocytosis. Also useful in immunocompromised patients or when systemic illness is suspected. MBS Item 66515.

Available

Monospot / Heterophile Antibody Test

Rapid test for EBV mononucleosis in adolescents/adults. Sensitivity ~85% in adults, low in children <12 years. Available through all major Australian pathology providers.

Available

EBV-Specific Serology

VCA IgM/IgG, EBNA, EA — for definitive EBV diagnosis when Monospot is negative but clinical suspicion remains. More sensitive in children.

Referral

CT Neck with Contrast

Indicated for suspected deep space neck infections (parapharyngeal, retropharyngeal abscess), Lemierre syndrome, or diagnostic uncertainty in peritonsillar pathology. MBS Item 56000 (CT) — hospital-based investigation.

Specialist

Intraoral Ultrasound

Point-of-care ultrasound in ED for peritonsillar abscess assessment. Operator-dependent. Increasingly available in Australian tertiary EDs. Can differentiate cellulitis from abscess and guide aspiration.

Specialist

Blood Cultures

Not routine for uncomplicated pharyngitis. Indicated in toxic/septic patients, suspected Lemierre syndrome, or immunocompromised patients. MBS Item 69310.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health — Sore Throat and Rheumatic Fever Prevention

The management of sore throat in Aboriginal and Torres Strait Islander populations has unique and critical significance due to the disproportionate burden of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in these communities. Any sore throat in an Aboriginal or Torres Strait Islander person living in an ARF-endemic area (Northern Territory, Far North Queensland, northern Western Australia) must be considered a potential GAS infection and managed accordingly.

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Critical: In ARF-endemic regions, RADT-negative sore throats in high-risk individuals should still receive empirical antibiotic therapy (or intramuscular benzathine penicillin) pending throat culture results. A single missed GAS infection can lead to ARF and lifelong RHD. This is a departure from standard low-risk management and reflects the elevated public health stakes.

ARF/RHD Burden

Aboriginal and Torres Strait Islander Australians experience ARF at rates 60–120 times higher than non-Indigenous Australians. RHD affects approximately 3% of Aboriginal and Torres Strait Islander people in high-prevalence communities. The median age of ARF onset in Indigenous Australians is 14 years — predominantly children and adolescents.

Sore Throat as ARF Sentinel Event

Up to 70% of ARF episodes are preceded by pharyngitis within the preceding 1–5 weeks. Many children do not report sore throat symptoms, or present late. Active sore throat surveillance programs operate in some remote communities. GPs should have a low threshold for swabbing and treating sore throats in this population.

Treatment Adherence

Oral antibiotic courses are frequently incomplete due to social determinants (transient living situations, limited pharmacy access, health literacy barriers). Intramuscular benzathine penicillin G (single injection) is the preferred treatment for confirmed or suspected GAS pharyngitis in ARF-endemic communities, as it ensures complete treatment and ARF prevention.

Remote & Very Remote Access

Many Aboriginal and Torres Strait Islander communities rely on Aboriginal Community Controlled Health Organisations (ACHOs) and remote area nurses (RANs) for primary care. RADT availability should be ensured at all remote clinics. Telehealth ENT consultations are increasingly used for complex cases. Royal Flying Doctor Service (RFDS) facilitates emergency transfers for PTA or airway compromise.

Secondary Prophylaxis

Patients with a history of ARF require long-term secondary prophylaxis with benzathine penicillin G every 28 days (21–28 day interval in high-risk cases) to prevent recurrent ARF and RHD progression. Sore throat in these patients is managed by the primary care team with awareness of their ARF history and prophylaxis status. See RHDAustralia guidelines for details.

Cultural Safety

Clinicians should provide culturally safe care: use of Aboriginal health practitioners and interpreters where appropriate, understanding of shame and health beliefs, family-centred consultations, and a non-judgemental approach to missed appointments or delayed presentations. Involve the patient's community and family in management discussions where appropriate.

📚 References

1. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of Group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86–e102.
2. McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75–83.
3. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book). 9th ed. Melbourne: RACGP; 2018.
4. RHDAustralia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
5. Australian Commission on Safety and Quality in Health Care (ACSQHC). Australian Atlas of Healthcare Variation. Sydney: ACSQHC; 2018. Section: Antibiotic dispensing.
6. Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984;310(11):674–683.
7. National Health and Medical Research Council (NHMRC). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: NHMRC; 2019.
8. Herzon FS. Harris P. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope. 1995;105(8 Pt 3 Suppl 74):1–17.
9. Australian Group on Antimicrobial Resistance (AGAR). Antimicrobial Resistance and Use in Australia. Canberra: Department of Health; 2023.
10. Australian Institute of Health and Welfare (AIHW). Rheumatic heart disease and acute rheumatic fever in Australia: 2017–2018. Cat. no. CVD 86. Canberra: AIHW; 2020.
11. Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989–1999. JAMA. 2001;286(10):1181–1186.
12. Ebell MH, Smith MA, Barry HC, Ives K, Carey M. The rational clinical examination. Does this patient have strep throat? JAMA. 2000;284(22):2912–2918.
13. SIGN (Scottish Intercollegiate Guidelines Network). Management of Sore Throat and Indications for Tonsillectomy: A National Clinical Guideline. SIGN 117. Edinburgh: SIGN; 2010.
14. NPS MedicineWise. Antibiotic prescribing for upper respiratory tract infections. Sydney: NPS MedicineWise; 2023.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).