What it is
FeverPAIN is a five-item clinical score that estimates the likelihood of streptococcal pharyngitis to guide antibiotic decisions in acute sore throat. Derived from the PRISM/DESCARTE work, it was designed to reduce unnecessary prescribing while still treating those most likely to benefit. The name is a mnemonic for its components.
The criteria
Each feature scores +1 (maximum 5):
- Fever in the last 24 hours
- Purulence (pus on the tonsils)
- Attend rapidly — presentation ≤3 days from onset
- Inflamed tonsils (severely)
- No cough or coryza
Interpretation bands
| Score | Likelihood of strep | Suggested action (NICE NG84) |
|---|---|---|
| 0–1 | ~13–18% | No antibiotic |
| 2–3 | ~34–40% | Consider a delayed (back-up) prescription |
| 4–5 | ~62–65% | Consider an immediate or delayed antibiotic |
When to use it
In the patient ≥3 years with acute sore throat, to decide between no antibiotic, a back-up prescription, and immediate treatment. It is an alternative to the Centor/McIsaac approach; many UK services use FeverPAIN as the default per NICE. Use it to rationalise — not mandate — prescribing.
Worked example
A 9-year-old, sore throat for 2 days. Fever yesterday (+1), pus on tonsils (+1), presented day 2 so attends rapidly (+1), tonsils severely inflamed (+1), but has a cough (0).
Score 4/5 → high (~62–65% strep). Consider an immediate or delayed antibiotic, factoring in the child’s overall illness and your local policy.
Pitfalls
- GAS pharyngitis is uncommon under age 3, and the score is not validated below that age — do not apply it to toddlers/infants.
- The score predicts streptococcal likelihood, not who will suffer complications; most sore throats are self-limiting regardless.
- Delayed prescribing is the deliberate middle option for scores 2–3 — write it as back-up, not as automatic treatment.
- Distinguish from Centor/McIsaac: different items (FeverPAIN has no age adjustment and no anterior-node criterion) and different bands — don’t mix cutoffs.
- Always overlay red flags (stridor, drooling, trismus, unilateral swelling suggesting peritonsillar abscess) — these override any score.
- Combine with clinical judgement and local testing/prescribing policy.
Run it: FeverPAIN Score (Pharyngitis)
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.