Is antibiotic treatment always necessary for streptococcal (strep) pharyngitis in adults?

From the Guidelines

Strep throat in adults does not always require antibiotic treatment, and the decision to treat should be based on test confirmation, symptom severity, and risk factors. According to the most recent and highest quality study 1, antibiotics like penicillin V (250-500 mg orally twice daily for 10 days) or amoxicillin (500 mg orally twice daily for 10 days) are typically recommended for confirmed strep throat. However, for penicillin-allergic patients, alternatives include cephalexin, azithromycin, or clindamycin. The study suggests that antibiotics shorten the duration of sore throat by 1 to 2 days, but the benefit is modest and the number needed to treat to reduce symptoms is 6 after 3 days of treatment and 21 after 1 week of treatment.

Some key points to consider when deciding on treatment include:

• The typical course of a sore throat is less than 1 week, and antibiotics are usually not needed because they do little to alleviate symptoms and may have adverse effects 1
• Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis by rapid antigen detection test and/or culture for group A Streptococcus, and treat patients with antibiotics only if they have confirmed streptococcal pharyngitis 1
• For mild cases in otherwise healthy adults with no risk factors, symptomatic treatment with rest, fluids, salt water gargles, and over-the-counter pain relievers may be sufficient
• Antibiotics help reduce symptom duration, prevent complications like rheumatic fever or kidney inflammation, and decrease contagiousness, but the benefits must be weighed against the potential risks and adverse effects 1

It is essential to consult a healthcare provider for proper diagnosis and treatment recommendations based on your specific situation.

From the FDA Drug Label

In streptococcal infections, therapy must be sufficient to eliminate the organism (10-day minimum); otherwise the sequelae of streptococcal disease may occur. NOTE: Penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever. Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy.

Treatment of strep throat with antibiotics in adults is recommended to eliminate the organism and prevent sequelae of streptococcal disease.

• Penicillin is the usual drug of choice for the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever.
• Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy 2, 2.
• The duration of therapy should be sufficient to eliminate the organism, with a minimum of 10 days 3.

From the Research

Treatment of Strep Throat with Antibiotics in Adults

• The use of antibiotics to treat strep throat in adults is not always necessary, as most cases of sore throat are caused by viral infections, not bacterial infections 4.
• According to guidelines, antibiotics should only be prescribed after a diagnosis of group A beta-hemolytic streptococcal pharyngitis has been confirmed, using clinical decision rules and rapid antigen testing if necessary 4, 5.
• Penicillin and amoxicillin are commonly recommended as first-line antibiotics for the treatment of strep throat in adults, with a recommended course of 10 days 4, 5.
• However, studies have shown that antibiotics provide only modest benefit in treating sore throat, and their effectiveness increases in people with positive throat swabs for group A beta-haemolytic streptococci (GABHS) 6, 7, 8.
• The decision to prescribe antibiotics should be made on a case-by-case basis, taking into account the individual's symptoms, medical history, and the potential risks and benefits of antibiotic treatment 8.

Alternatives to Antibiotics

• For adults with strep throat, treatment with antibiotics may not always be necessary, and alternative treatments such as pain relief medications and rest may be sufficient 4, 5.
• In some cases, watchful waiting may be recommended, where the patient is monitored for a period of time to see if the symptoms resolve on their own before antibiotics are prescribed 4, 5.
• However, it is essential to note that antibiotics are necessary for certain cases, such as those with a confirmed diagnosis of group A beta-hemolytic streptococcal pharyngitis, to prevent complications and reduce the risk of transmission to others 4, 5, 6, 7, 8.

Considerations for Antibiotic Use

• The overuse of antibiotics is a concern, and clinicians must weigh the potential benefits of antibiotic treatment against the risks of antimicrobial resistance and other adverse effects 6, 7, 8.
• The choice of antibiotic should be based on the individual's medical history, allergy status, and the local resistance patterns of the bacteria 4, 5, 6, 7.
• Clinicians should also consider the potential for adverse effects, such as allergic reactions, and monitor patients closely for any signs of complications or resistance 4, 5, 6, 7, 8.