What is the FeverPAIN score?
FeverPAIN is a clinical score for acute sore throat. It estimates the chance of streptococcal infection.
It was developed in UK primary care by Little and colleagues. It helps you decide whether an antibiotic is worthwhile.
NICE guideline NG84 recommends FeverPAIN or Centor for sore throat. Most UK GPs and pharmacists now use FeverPAIN.
The five FeverPAIN criteria
Each criterion scores one point. The maximum score is 5.
- Fever in the past 24 hours
- Purulence: pus on the tonsils
- Attend rapidly: within 3 days of symptom onset
- Inflamed tonsils: severely inflamed
- No cough or coryza
FeverPAIN score interpretation
| Score | Chance of streptococcus | NICE NG84 plan |
|---|---|---|
| 0–1 | 13–18% | No antibiotic. Self-care and pain relief. |
| 2–3 | 34–40% | Consider no antibiotic or a back-up prescription. |
| 4–5 | 62–65% | Consider an immediate antibiotic or a back-up prescription. |
A back-up prescription is used only if symptoms worsen or fail to settle. Agree a clear plan with the patient.
If an antibiotic is needed
NICE NG84 lists phenoxymethylpenicillin as first line. Clarithromycin is the usual choice for penicillin allergy. Erythromycin is preferred in pregnancy. Check doses in the BNF and your local formulary.
FeverPAIN vs Centor
Both scores are accepted by NICE. They use different criteria and thresholds.
| FeverPAIN | Centor | |
|---|---|---|
| Origin | UK primary care | US emergency department, adults |
| Criteria | Fever, purulence, attend rapidly, inflamed tonsils, no cough or coryza | Tonsillar exudate, tender anterior neck nodes, history of fever, no cough |
| Score range | 0–5 | 0–4 |
| Antibiotic threshold | Consider at 4–5 | Consider at 3–4 |
When to use it, and when not to
- Use it for acute sore throat, pharyngitis and tonsillitis in primary care.
- It was derived in patients aged 3 and over.
- Pharmacists use it in the NHS Pharmacy First sore throat pathway.
- Do not rely on the score if the patient is systemically very unwell.
- Look for complications such as quinsy, and for signs of epiglottitis.
- Take extra care in immunosuppression, including neutropenia.