What antibiotic is recommended for pharyngitis (sore throat)?

From the Guidelines

Antibiotics are generally not recommended for most sore throats, but if a healthcare provider confirms strep throat, the standard antibiotic treatment is penicillin V potassium or amoxicillin. According to the most recent and highest quality study 1, for patients diagnosed with group A streptococcal infection, antibiotics shorten the duration of sore throat by 1 to 2 days. The recommended treatment duration is usually 10 days with an appropriate narrow-spectrum antibiotic.

Key Points:

• Most sore throats are caused by viral infections and do not respond to antibiotics.
• For strep throat, penicillin V potassium (250-500 mg orally twice daily for 10 days) or amoxicillin (500 mg twice daily or 1000 mg once daily for 10 days) are the standard treatments.
• For those allergic to penicillin, alternatives include cephalexin (if not severely allergic), azithromycin, or clindamycin.
• It's crucial to complete the full course of antibiotics even if symptoms improve to prevent complications and antibiotic resistance.
• While waiting for antibiotics to work, symptoms can be managed with over-the-counter pain relievers like acetaminophen or ibuprofen, warm salt water gargles, and staying hydrated.

Management Strategies:

• Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis by rapid antigen detection test and/or culture for group A Streptococcus.
• Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
• Adult patients with sore throat should be offered analgesic therapy to help reduce pain.
• Patients can be assured that the typical course of a sore throat is less than 1 week and that antibiotics are usually not needed because they do little to alleviate symptoms and may have adverse effects.

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%)

Azithromycin is effective for the treatment of pharyngitis/tonsillitis caused by Group A β-hemolytic streptococci, with a clinical success rate of 98% at Day 14 and 94% at Day 30 2.

• The recommended dose for children is 12 mg/kg once daily for 5 days.
• Azithromycin was statistically superior to penicillin in terms of clinical success and bacteriologic efficacy.

From the Research

Antibiotic Treatment for Sore Throat

• The most common bacterial cause of pharyngitis is Group A β-hemolytic streptococcus (GABHS), and antibiotics are only necessary for bacterial infections 3, 4, 5, 6.
• Guidelines recommend using clinical decision rules to assess the risk of GABHS infection, followed by rapid antigen testing if a diagnosis is unclear, before prescribing antibiotics 4, 5, 6.
• Penicillin and amoxicillin are first-line antibiotics for treating GABHS, with a recommended course of 10 days 4, 5.
• First-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 4, 5.
• There is significant resistance to azithromycin and clarithromycin in some parts of the United States, making them less effective options 4.

Diagnosis of Sore Throat

• A careful physical examination and patient history is the starting point for diagnosing GABHS 6.
• Diagnostic methods include clinical scoring systems, rapid antigen detection tests, throat culture, nucleic acid amplification tests, and machine learning and artificial intelligence 6.
• Clinical guidelines developed by professional associations can help medical professionals choose among available techniques to diagnose strep throat 6.
• However, guidelines for diagnosing GABHS vary significantly, and there is substantial evidence that most physicians do not follow any published guidelines 6.

Appropriate Use of Antibiotics

• Antibiotics should only be prescribed for bacterial infections, and a throat swab with a rapid antigen detection test and/or culture should be performed for all patients with symptoms of pharyngitis 7.
• Patients receiving a throat swab show a significantly increased odds of antibiotic prescription 7.
• Provider counseling on current recommendations of antibiotic prescription practices is necessary to reduce unnecessary antibiotic use 7.