Primary Care
FeverPAIN Score
Likelihood of streptococcal sore throat.
Education and reference only. Not a substitute for clinical judgement, local policy or product labelling. Always verify before clinical use. Values are calculated in your browser and never stored.
Background
FeverPAIN is a five-point clinical score used in acute sore throat to estimate the likelihood of a streptococcal infection and to guide antibiotic decisions. One point is given for each of: Fever in the previous 24 hours, Purulence on the tonsils, Attending rapidly (within three days of onset), severely Inflamed tonsils, and No cough or coryza. It was developed in UK primary care to support antibiotic stewardship by targeting those most likely to have a bacterial cause. It is recommended by NICE alongside or as an alternative to the Centor criteria.
Interpreting the result
A score of 0–1 carries a low likelihood of streptococcus (around 13–18%), so antibiotics are usually not needed. A score of 2–3 is intermediate (around 34–40%) and may justify a delayed (back-up) prescription. A score of 4–5 carries a higher likelihood (around 62–65%), and antibiotics can reasonably be considered. The score is a stewardship aid; safety-netting and clinical judgement, including looking for red flags of serious illness, remain essential.
Worked example
A patient presents within two days of onset with fever in the last 24 hours, pus on the tonsils, severely inflamed tonsils and no cough — that is fever (1), purulence (1), attend rapidly (1), inflamed tonsils (1), no cough (1) = 5. This high score supports considering an antibiotic, with safety-netting.
Pearls / pitfalls
- It supports a delayed or back-up prescribing strategy, which is often appropriate for intermediate scores.
- It estimates the likelihood of streptococcus, not the severity of illness, so it does not replace assessment for complications such as quinsy.
- It is validated in adults and older children, and should be applied with caution in very young children.
- A throat swab is not routinely needed; the score and clinical picture usually suffice, with safety-netting.
Evidence & validation
Derived and validated in the PRISM study by Little and colleagues (published in Health Technology Assessment in 2014), where score-guided management reduced antibiotic use without compromising outcomes; it is endorsed by NICE for assessing acute sore throat.
Frequently asked questions
What FeverPAIN score suggests antibiotics?
A score of 4–5 carries a higher likelihood of streptococcus (around 62–65%) and supports considering antibiotics. A score of 0–1 is low risk and usually does not need them, while 2–3 may warrant a delayed prescription.
How does FeverPAIN differ from the Centor criteria?
Both estimate the likelihood of streptococcal sore throat, but FeverPAIN adds rapid attendance and tonsil purulence and uses different items. NICE recommends either, with FeverPAIN derived more recently in UK primary care.
What is a delayed prescription?
A delayed or back-up prescription is given but the patient is advised to use it only if symptoms do not settle or worsen. This is often appropriate for intermediate scores and reduces overall antibiotic use.
Does a high score confirm a bacterial infection?
No. Even at the top of the range the likelihood of streptococcus is well under certainty, so the score guides the probability and the prescribing decision rather than confirming a diagnosis.
Can it be used in children?
It was validated in adults and older children. In very young children the clinical picture differs, so it should be applied cautiously and alongside careful assessment for serious illness.
References
- Little P, Hobbs FDR, Moore M, et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: PRImary care Streptococcal Management (PRISM). Health Technol Assess. 2014;18(6).
- NICE NG84: Sore throat (acute): antimicrobial prescribing. 2018.
About the creator
Little P et al.
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