From the Guidelines
Treatment for acute pharyngitis, particularly Group A Streptococcus, should include penicillin or amoxicillin as the first-line antibiotic for 10 days, as recommended by the Infectious Diseases Society of America 1. For viral pharyngitis, which accounts for the majority of cases, treatment is focused on symptomatic management, including:
- Rest
- Adequate hydration
- Saltwater gargles
- Throat lozenges
- Over-the-counter pain relievers like acetaminophen (325-650 mg every 4-6 hours) or ibuprofen (400-600 mg every 6-8 hours) However, for bacterial pharyngitis, antibiotics are necessary to reduce symptom duration, prevent complications like rheumatic fever, and decrease contagiousness.
- First-line treatment is penicillin V (250-500 mg orally twice daily for 10 days) or amoxicillin (500 mg twice daily or 1000 mg once daily for 10 days), as these have a narrow spectrum of activity, are cost-effective, and have long-standing proven efficacy 1.
- For penicillin-allergic patients, alternatives include a first-generation cephalosporin (for those not anaphylactically sensitive), clindamycin, or azithromycin, with specific dosing regimens such as azithromycin (500 mg on day 1, then 250 mg daily for 4 days) 1. It is crucial to confirm the diagnosis with rapid strep testing or throat culture before starting antibiotics to avoid unnecessary use, and patients should complete the full antibiotic course even if symptoms improve quickly to ensure complete bacterial eradication.
From the FDA Drug Label
Pharyngitis/Tonsillitis In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes)
Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS):
Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS
Day 14Day 30
Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%)
Penicillin V242/332 (73%)206/325 (63%)
Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%)
Penicillin V284/338 (84%)241/325 (74%)
Treatment options for acute pharyngitis include:
- Azithromycin: 12 mg/kg once a day for 5 days, which has been shown to be clinically and microbiologically statistically superior to penicillin V at Day 14 and Day 30 2
- Penicillin V: 250 mg three times a day for 10 days, which is also effective in treating pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) 3
From the Research
Treatment Options for Acute Pharyngitis
- The primary goal of treatment is to prevent suppurative and nonsuppurative complications, alleviate clinical signs and symptoms, reduce bacterial transmission, and minimize antimicrobial adverse effects 4.
- Antibiotic selection should consider patients' allergies, bacteriologic and clinical efficacy, frequency of administration, duration of therapy, potential side effects, compliance, and cost 4.
- Oral penicillin remains the drug of choice in most clinical situations, although cephalosporins and amoxicillin-clavulanate potassium may provide superior bacteriologic and clinical cure rates 4, 5.
- Alternative treatments, such as erythromycin, should be used in patients with penicillin allergy 5.
- For patients who do not respond to initial treatment, an antimicrobial that is not inactivated by penicillinase-producing organisms (e.g., amoxicillin-clavulanate potassium, a cephalosporin, or a macrolide) should be considered 4.
- A 10-day course of oral penicillin or an intramuscular injection of penicillin G benzathine is recommended for the treatment of group A beta-hemolytic streptococcal pharyngitis 5, 6.
- Clinical scoring systems, such as the modified Centor score, can be used to predict the risk of S. pyogenes infection and guide treatment decisions 6, 7.
- Rapid antigen detection tests and throat cultures can be used to confirm the diagnosis of streptococcal pharyngitis 4, 5, 6, 7.
- Steroids are not recommended for symptomatic treatment, and tonsillectomy is rarely recommended as a preventive measure 7.