What are the symptoms and treatment options for a patient with streptococcal pharyngitis (strep throat) presenting with a cough?

From the Guidelines

Strep throat with cough should be treated with antibiotics, specifically penicillin or amoxicillin, for a full 10-day course, as recommended by the Infectious Diseases Society of America 1.

Key Considerations

• The presence of a cough does not rule out strep infection, and a rapid antigen detection test and/or culture for group A Streptococcus should be performed to confirm the diagnosis 1.
• For adults, the standard dose is penicillin V 500 mg twice daily or amoxicillin 500 mg twice daily, while for those allergic to penicillin, alternatives include azithromycin or clindamycin 1.
• Antibiotics help prevent complications like rheumatic fever and kidney inflammation, and reduce contagiousness after 24 hours of treatment 1.

Symptom Relief

• Take acetaminophen or ibuprofen for pain and fever
• Gargle with warm salt water
• Use throat lozenges
• Drink plenty of fluids
• Rest your voice

Important Notes

• If symptoms worsen or don't improve after 48 hours of antibiotics, consult a healthcare provider for reevaluation 1.
• Antibiotics are not recommended for chronic group A Streptococcus carriers, as they are unlikely to spread infection to close contacts and are at little or no risk for complications 1.

From the FDA Drug Label

In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum): otherwise the sequelae of streptococcal disease may occur. Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy

Strep throat treatment:

• Penicillin is the first-line therapy for strep throat, and it should be taken for a minimum of 10 days to eliminate the organism.
• Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy.
• A cough may be present in patients with strep throat, but the primary treatment is aimed at eliminating the streptococcal infection.
• It is essential to complete the full course of therapy as directed to prevent the development of drug-resistant bacteria and ensure effective treatment 2, 3.

From the Research

Strep Throat with Cough

• A cough is more suggestive of a viral etiology rather than strep throat, according to 4
• The strongest independent predictors of GABHS pharyngitis are patient age of five to 15 years, absence of cough, tender anterior cervical adenopathy, tonsillar exudates, and fever, as stated in 5
• Guidelines recommend using clinical decision rules to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear, before prescribing antibiotics, as mentioned in 4

Diagnosis and Treatment

• Available diagnostic tests include throat culture and rapid antigen detection testing, with throat culture being the diagnostic standard, as noted in 6
• Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice due to cost, narrow spectrum of activity, and effectiveness, according to 6
• Amoxicillin is equally effective and more palatable, while erythromycin and first-generation cephalosporins are options in patients with penicillin allergy, as stated in 6

Antibiotic Treatment

• Antibiotics provide only modest benefit in treating sore throat, although their effectiveness increases in people with positive throat swabs for group A beta-haemolytic streptococci (GABHS), as mentioned in 7 and 8
• It is unclear which antibiotic is the best choice if antibiotics are indicated, with low-certainty evidence suggesting that carbacephem may be more effective than penicillin for symptom resolution in adults and children, according to 7 and 8