Earlier this week I received an email asking my opinion of an ER sore throat policy.  The question focused on acute rheumatic disease prevention, and ask my opinion on testing and treatment.  Here is my short answer:

This is a classic question.  I will provide a fairly long answer.

I know of 5 reasons to treat sore throats.  Each deserves some discussion.
 

1. Prevent rheumatic fever.  In North America this rationale is no longer important.  We have very little rheumatic fever, and your estimates seem rational. We see no major difference in this rare complication regardless of strategy.
2. Prevent suppurative complications.  Antibiotics do decrease the incidence of peritonsillar abscess – quoting from Cochrane: “Antibiotics reduced the incidence of acute otitis media (RR 0.30; 95% CI 0.15 to 0.58); of acute sinusitis (RR 0.48; 95% CI 0.08 to 2.76); and of quinsy (peritonsillar abscess) compared to those taking placebo (RR 0.15; 95% CI 0.05 to 0.47).”
3. Shorten duration of symptoms – clearly when adult patients have group A strep they have symptom resolution faster, especially when their symptoms are more severe
4. Decrease spread to close contacts – antibiotics markedly reduce transmission
5. Prevent death – the very rare patient with strep will suffer streptococcal shock syndrome – probably not a reason to consider antibiotics

Experts greatly disagree on these issues and their relative importance.  I treat sick pharyngitis patients knowing that I decrease the risk of suppurative complications (although we do not eliminate that risk) and to decrease the duration of their illness.
 

An underpinning of this "controversy" involves an understanding of the microbiology of tonsillitis and pharyngitis.  Most physicians (including many experts) only worry about Group A strep.  As readers know I worry about the common non-group A strep – Group C and Group G.  Obviously, I am also quite worried about Fusobacterium necrophorum. While rare, Neiserria gonorrheae can cause suppurative pharyngitis. 

Other important considerations in the differential include acute HIV infection, EBV, chlamydia and mycoplasma.  Finally, we must always think about the initial presentation of suppurative disease (especially peritonsillar abscess.)

The problem with adult sore throats is that most physicians consider them simple, routine and uninteresting.  In fact, the management of most pharyngitis is simple and routine, but just because most patients have a viral infection or strep throat does not mean we should not think carefully about each patient.  We have a responsibility to understand the red flags for even this seemingly routine problem.