Management of Sore Throat with Leukocytosis and Neutrophilia

Initial Clinical Assessment

The American Academy of Family Physicians recommends using the Centor criteria to risk-stratify patients with sore throat, and performing a rapid antigen detection test (RADT) or throat culture if 3-4 criteria are present, and treating with penicillin V for 10 days only if Group A streptococcus is confirmed or if high clinical suspicion exists with positive testing 1, 2
The presence of fever by history is one of the Centor criteria used to determine the likelihood of Group A streptococcal infection, with a score of 1 point 4
The presence of tonsillar exudates is one of the Centor criteria used to determine the likelihood of Group A streptococcal infection, with a score of 1 point 3
The absence of cough is one of the Centor criteria used to determine the likelihood of Group A streptococcal infection, with a score of 1 point 3

For patients with 0-2 Centor criteria, the Infectious Diseases Society of America recommends not performing testing and not prescribing antibiotics, as the likelihood of Group A streptococcus is low and most cases are viral 1, 2, 4
For patients with 3-4 Centor criteria, the American Academy of Pediatrics recommends performing a rapid antigen detection test (RADT) immediately, with a specificity >95% and sensitivity ≥90% 1, 2, 3
If RADT is positive, the American Academy of Family Physicians recommends treating with antibiotics (no throat culture needed) 1
If RADT is negative, the Infectious Diseases Society of America recommends confirming with throat culture before treating 1, 2

The American College of Physicians recommends symptomatic management for all patients, including ibuprofen or paracetamol for pain relief regardless of etiology 1, 2
Antibiotic therapy should not be used in patients with 0-2 Centor criteria to relieve symptoms, due to the modest benefits and potential side effects, antimicrobial resistance, and costs 1, 2, 4
If antibiotics are indicated (positive RADT or culture in patient with 3-4 Centor criteria), the American Academy of Pediatrics recommends penicillin V 500 mg orally twice daily or 250 mg three times daily for 10 days 1, 5, 4
For penicillin allergy, the Infectious Diseases Society of America recommends erythromycin or other macrolide 5

The American Heart Association notes that prevention of complications is not a primary indication for antibiotics in low-risk patients, as suppurative complications (quinsy, otitis media, sinusitis) occur rarely and do not justify routine antibiotic use 4, 6
Acute rheumatic fever and glomerulonephritis are extremely rare in Europe and should not drive treatment decisions in patients without prior rheumatic fever history, according to the European Society of Cardiology 6, 4
Asymptomatic carriage of Group A streptococcus is common, with up to 20% of school children carrying the bacteria asymptomatically, and having an extremely low risk of complications or transmission, as noted by the Centers for Disease Control and Prevention 6, 5