"My sore throats, you know, are always worse than anybody's."
So declares Mary to Anne in "Persuasion," Jane Austen's 1817 book. Most of us can relate to this feeling. There is no such thing as "just a sore throat." The pain, headache, fever and aches associated with a sore throat can make you feel terrible.
While sore throats can occur at any time of year, strep throat is more common in the fall, winter and early spring.
I am a professor of family medicine, a pharmacist and an expert on evidence-based medicine. My work involves the evaluation of research performed by others, and I have been following and analyzing research findings on strep for the past 30 years.
Many people incorrectly assume that all sore throats are due to strep throat, a bacterial infection of the pharynx, the middle throat area behind the nose and mouth, and patients often come to our family medicine office wanting to be checked and treated for strep with antibiotics.
However, neither testing nor treatment is always needed for a sore throat. Regardless of the cause, rest and pain relievers form the cornerstone of sore throat treatment.
Here's some guidance on whether and when testing is necessary.
Bacterial versus viral sore throats
Most sudden-onset sore throats are caused by viruses - the same ones that cause the common cold, the seasonal flu and COVID-19. There are more than 200 viruses that can cause sore throat and other symptoms related to the common cold.
But bacteria can also be the culprits behind a sore throat. One of the most common examples is strep throat, or group A pharyngitis.
Strep is caused by certain strains of Streptococcus pyogenes bacteria. There are many species of strep; other common forms of strep that cause different infections in humans include "group B strep" and "group D strep." Group A strep usually lives peacefully among the many other types of bacteria growing on our skin and doesn't cause any problems, until we get a break in the skin such as a cut or a scrape. This allows it to overwhelm the immune system's ability to keep it in check.
Group A strep can also live in the back of the throat - up to 30% of people without any evidence of a sore throat will have this strain in their throat. Up to 3 in 10 children and 1 in 10 adults feeling sick with a sore throat due to a virus or other cause will test positive for group A strep. That means that people with a sore throat caused by a virus could also be positive for strep, even if it's not causing the symptoms.
Not all group A strep bacteria are the same, though. Some varieties are better at evading the immune system than others and can grow quickly. Others produce byproducts that can cause a sore throat and sometimes lead to tonsillitis, an infection of the tonsils, or cause ear or sinus infections.
Still other strep strains produce a toxin that can cause a characteristic skin rash or lead to effects on the heart, kidneys or even the brain.
Rarer still, group A strep can enter the bloodstream and cause toxic shock syndrome, a life-threatening, overwhelming infection. These latter conditions are examples of invasive strep, meaning that the infection is in parts of the body typically free from germs; they seem to be on the rise after a marked reduction in their occurrence during the COVID-19 pandemic.
To test or not to test
Doctors or other clinicians can easily test for strep by using a swab to collect a bit of the fluid from the back of the throat. This sample can identify group A strep in about a minute.
While researchers have been studying group A strep for over 75 years and there are thousands of research papers focused on infections caused by strep, there is still controversy over whether it needs to be tested for and treated.
