Worldwide Comparison of Treatment Guidelines for Sore Throat

Sore throat (acute pharyngitis) is globally one of the most frequent reasons for seeking healthcare. Its etiology is mostly viral. In 15-30% of cases, group A streptococci (GAS) are detected, which may cause acute rheumatic fever. We have done a worldwide systematic review to compare diagnostic and therapeutic guidelines across countries and regions. Previous reviews of sore throat guidelines were limited to specific regions and/or language; this is the first global review. Searches were performed in MEDLINE, EMBASE and COCHRANE (key words: sore throat, pharyngitis, tonsillitis or pharyngotonsillitis, and management, guidance, guideline or recommendation) and on the web sites of major health authorities and associated institutions from Africa, Asia, Europe, Middle East, North America, Oceania and South America. Thirty-six guidelines were identified from 26 countries. Most common are recommendations relying on the symptom- and age-based Centor or McIsaac scores. However, antibiotic treatment may be based on other symptomatic criteria; in the most extreme approach just sore throat in children. The recommendation of GAS-specific diagnostic tests is mainly limited to countries where such tests are readily available, although some countries choose not to use them. Penicillins are consistently recommended as first-line antibiotics. By contrast, guidance for symptomatic treatment is variable and mostly sparse or missing. African countries without sore throat guidelines and Asian countries bypassing them are afflicted by rising antibiotic resistance. The availability of sore throat guidelines varies considerably by region and country. Moreover, important divergence is found among the guidelines regarding diagnostic and treatment criteria. This may be explained by the historical background or adoption of external guidelines, rather than the local incidences of GAS infections or acute rheumatic fever. Absence of recommendations on symptomatic treatment in many guidelines is concerning, and raises issues about antimicrobial stewardship, as this is the mainstay of sore throat management, rather than antibiotics.