FeverPAIN score

The FeverPAIN score is a clinical prediction rule used in primary care to estimate the likelihood of streptococcal pharyngitis in patients presenting with acute sore throat. It is designed to support antibiotic prescribing decisions and reduce unnecessary antimicrobial use.

The score is recommended in UK primary care guidance as part of a structured approach to sore throat assessment.

Clinical use

FeverPAIN is intended for use in acute presentations of sore throat, typically within the first few days of symptom onset. It is most commonly applied in adults and older children presenting to general practice, urgent care, or community settings.

The score estimates the probability of group A beta-haemolytic streptococcal infection and helps stratify patients into groups where antibiotics are unlikely to help, may be considered, or are more likely to be beneficial.

The score is based on five clinical features. One point is awarded for each criterion present:

• Fever during the previous 24 hours

• Purulence, defined as tonsillar exudate

• Attendance within 3 days of symptom onset

• Severely inflamed tonsils

• No cough or coryza

The total score ranges from 0 to 5.

Lower scores indicate a low likelihood of streptococcal infection, where antibiotics are unlikely to provide meaningful benefit. Higher scores indicate an increasing probability of streptococcal pharyngitis and a greater likelihood of benefit from antibiotic treatment.

As a general guide used in UK practice:

• Scores of 0–1 suggest a low risk of streptococcal infection and support a no-antibiotic strategy.

• Scores of 2–3 suggest an intermediate risk, where a delayed antibiotic prescription may be appropriate depending on clinical judgement and patient factors.

• Scores of 4–5 suggest a higher risk, where immediate antibiotics may be considered.

Thresholds should be applied alongside clinical context and local antimicrobial stewardship guidance.

The FeverPAIN score was developed and validated in UK primary care populations. Studies have shown that its use can reduce immediate antibiotic prescribing without increasing complication rates, while maintaining patient satisfaction.

Compared with other sore throat scoring systems, FeverPAIN incorporates symptom duration and viral features, improving discrimination in early presentations.

Unlike the Centor score, FeverPAIN includes symptom duration and explicitly accounts for the absence of viral features such as cough or coryza. This makes it particularly useful in early presentations, where decision-making around antibiotics is often most challenging.

In UK primary care, FeverPAIN is generally preferred over Centor-based scores, although both may be encountered in clinical practice.

Sore throat is one of the most common reasons for antibiotic prescribing in primary care, despite most cases being self-limiting and viral in origin. The FeverPAIN score supports antimicrobial stewardship by:

• Providing an objective framework for prescribing decisions

• Supporting delayed prescription strategies

• Facilitating shared decision-making with patients

• Reducing unnecessary exposure to antibiotics

Use of the score should be combined with safety-netting advice and clear guidance on when to reconsult.

The FeverPAIN score does not replace clinical judgement. It should be used cautiously in patients with:

• Immunsuppression

• Significant comorbidities

• Red flag symptoms such as airway compromise, unilateral swelling, or systemic toxicity

• Recurrent or atypical presentations

The score is not designed to diagnose complications such as peritonsillar abscess or to guide management in severe systemic illness.

Using a structured score can help explain prescribing decisions to patients and may improve acceptance of non-antibiotic management. Documentation of the score can also support clinical governance and audit of antibiotic use.

Clear advice on symptom control, expected illness duration, and red flag symptoms remains essential, regardless of the score.