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FeverPAIN score

Likelihood of streptococcal (group A/C/G) sore throat in primary care, from 3 years of age

Sources last checked: 2026-10-13

FeverPAIN score

Likelihood of streptococcal (group A/C/G) sore throat in primary care, from 3 years of age

0
0–1 — unlikely to benefit from an antibiotic

Streptococci isolated in ≈ 13–18 %. NICE NG84 and DEGAM recommend no antibiotic prescription.

NICE groups scores 2–3 together; DEGAM separates ≤ 2 from 3 — both are shown. External validation outside the UK is limited, and the score does not predict suppurative complications well. Not for patients with red flags or systemic illness.

Source: Little P, Moore M, Hobbs FDR et al. PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A β-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open 2013;3(10):e003943.Open

Interpretation

0–1 — unlikely to benefit from an antibioticStreptococci isolated in ≈ 13–18 %. NICE NG84 and DEGAM recommend no antibiotic prescription.
2 — may benefitStreptococci in ≈ 34–40 % (scores 2–3). NICE recommends no antibiotic or a back-up prescription. DEGAM (score ≤ 2) recommends symptomatic treatment only.
3 — may benefitStreptococci in ≈ 34–40 % (scores 2–3). NICE recommends no antibiotic or a back-up prescription. DEGAM (score 3) provides for an antibiotic only as a delayed prescription.
4–5 — most likely to benefitStreptococci in ≈ 62–65 %. NICE recommends considering an immediate or back-up antibiotic. DEGAM names a delayed or immediate antibiotic as options.

What is the FeverPAIN score?

FeverPAIN predicts streptococcal (Lancefield group A, C or G) throat infection from five clinical features. It was developed by Little and colleagues in the UK PRISM primary-care cohorts and tested in a randomised trial published in 2013. NICE NG84 recommends it alongside Centor, and the German DEGAM guideline includes it.

When to use it

  • Acute sore throat in primary care from 3 years of age.
  • Choosing between no antibiotic, a back-up (delayed) prescription and an immediate antibiotic.
  • When group C and G streptococci are relevant — the score was built on A/C/G growth.

When not to use it

  • Systemically unwell patients, suspected quinsy or epiglottitis.
  • Red flags such as immunosuppression, scarlet-fever rash or suspected mononucleosis.
  • As a predictor of complications — it performs poorly for that.

How it is calculated

CriterionPoints
Fever during the previous 24 hours+1
Purulence (pus on the tonsils)+1
Attended rapidly (within 3 days of symptom onset)+1
Severely inflamed tonsils+1
No cough or coryza+1

Clinical pearls and limitations

  • NICE groups scores 2–3 together; DEGAM separates ≤ 2 from 3 — both are shown. External validation outside the UK is limited, and the score does not predict suppurative complications well. Not for patients with red flags or systemic illness.
  • 'Attend rapidly' means presenting within 3 days of symptom onset.
  • In the PRISM trial, using the score reduced antibiotic use by about 29 % and slightly improved symptoms.
  • NICE bands: 0–1 no antibiotic; 2–3 none or back-up; 4–5 immediate or back-up.
  • DEGAM bands differ at 2 and 3: ≤ 2 symptomatic only, 3 delayed prescription only.

Frequently asked questions

What does FeverPAIN stand for?

Fever in the past 24 h, Purulence, Attend rapidly (≤ 3 days), severely Inflamed tonsils, No cough or coryza.

Is FeverPAIN better than Centor?

It identified more low-risk patients in its derivation cohorts and covers group C/G streptococci, but external validation outside the UK is limited.

What is a back-up antibiotic prescription?

A prescription issued with advice to use it only if symptoms worsen or do not start to improve after a set time — the same idea as 'delayed prescribing'.

Evidence and guidelines

  1. Primary source: Little P, Moore M, Hobbs FDR et al. PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A β-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open 2013;3(10):e003943.
  2. Little P et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM. BMJ 2013;347:f5806.
  3. NICE NG84. Sore throat (acute): antimicrobial prescribing, 2018 — recommendations 1.1.5–1.1.11 and 'Terms used in the guideline'.
  4. DEGAM S3-Leitlinie Halsschmerzen (AWMF-Register 053-010), 2020, revidiert 12/2021 — Empfehlung 9.9 und Tabelle 8.2. Gültigkeit abgelaufen, in Überarbeitung.

Have a follow-up question?

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