Sore throat and tonsillitis: a case-based approach

The case: a painful throat and fever

A 15-year-old wakes with a raw, painful throat, a temperature, and swollen glands in the neck. Swallowing hurts and the tonsils look red with white flecks. This picture is extremely common and worries families, who often assume antibiotics are needed. In fact, most sore throats, including many that look like tonsillitis, are caused by viruses such as those behind colds and flu. These get better on their own as the immune system clears them, usually within about a week. The first task for a clinician is not to reach for a prescription, but to work out how likely a bacterial cause is and, above all, to rule out the rare but dangerous throat problems that need emergency care.

Viral or bacterial? The FeverPAIN idea

Because tonsillitis can be viral or bacterial, clinicians use simple scoring tools to estimate the chance of a bacterial (streptococcal) cause. In England the FeverPAIN score is common; the older Centor criteria are similar. In plain terms, they add up features such as a high fever, pus on the tonsils, tender neck glands, the absence of a cough, and how quickly symptoms began. A low score suggests a virus, where antibiotics offer little benefit and simple self-care is best. A higher score raises the chance of a bacterial cause, where antibiotics may modestly shorten symptoms. These scores guide decisions; they do not replace a clinician's judgement, and they are one reason a pharmacist or GP may not prescribe.

When antibiotics are and are not needed

For most people, antibiotics make little difference to a sore throat: they may shorten symptoms by around a day, carry side effects, and drive antibiotic resistance. That is why NHS guidance encourages self-care first, supported by a community pharmacist, who can advise on pain relief and soothing measures. Antibiotics are considered when the picture strongly suggests a bacterial infection, when someone is systemically very unwell, or when they are at higher risk of complications. Some pharmacies in England now run a sore throat service using scoring and, where offered, a swab test. The message is not that antibiotics never help, but that they are reserved for the minority who genuinely benefit rather than given routinely.

Self-care and the pharmacist-first pathway

Because most sore throats are self-limiting, the mainstay is comfort while the body recovers. Over-the-counter pain relief, taken as directed, eases the pain and lowers fever; warm or cool drinks, rest, and staying hydrated all help. Medicated lozenges, sprays, or salt-water gargles can soothe the throat, though they do not speed recovery. A community pharmacist is the ideal first port of call: they can suggest suitable products, check nothing more serious is going on, and advise when to see a GP. Most people improve steadily over a few days to a week. Antibiotics bought or borrowed without assessment are discouraged, as they are usually unnecessary and can cause harm.

Red flags that change the plan

A few throat problems are emergencies and must not be missed. Difficulty breathing, difficulty swallowing saliva, drooling, a muffled or hot-potato voice, or being unable to open the mouth can signal a serious infection around the throat, such as an abscess or, rarely, a swollen epiglottis; these need urgent hospital care, so phone 999. Also seek same-day medical advice if symptoms are severe, if a very sore throat lasts more than about a week, if someone becomes dehydrated, or if they have a weakened immune system. A widespread rash, or a sore throat in someone taking a medicine that can affect the immune system, should prompt urgent review rather than waiting it out.