From the Guidelines
Pharyngitis should be managed with supportive care, and antibiotic treatment should only be initiated if streptococcal pharyngitis is confirmed through testing, with penicillin V or amoxicillin being the recommended first-line treatment options 1.
Diagnosis and Management
Pharyngitis is an inflammation of the throat, commonly known as a sore throat. Most cases are viral in nature and resolve on their own within 7-10 days with supportive care including:
- Rest
- Adequate hydration
- Over-the-counter pain relievers like acetaminophen (325-650mg every 4-6 hours) or ibuprofen (400-600mg every 6-8 hours)
- For symptomatic relief, warm salt water gargles (1/2 teaspoon salt in 8 ounces of warm water) and throat lozenges can be helpful
Antibiotic Treatment
If streptococcal pharyngitis (strep throat) is confirmed through testing, antibiotic treatment with penicillin V (adults: 500mg twice daily for 10 days; children: 250mg twice daily for 10 days) or amoxicillin (adults: 500mg twice daily for 10 days; children: 50mg/kg/day divided twice daily for 10 days) is recommended 1. For penicillin-allergic patients, azithromycin (500mg on day 1, then 250mg daily for 4 more days) is an alternative 1. Antibiotics help prevent complications like rheumatic fever and reduce contagiousness.
When to Seek Medical Attention
Pharyngitis warrants medical attention if:
- Symptoms persist beyond 7 days
- There's difficulty breathing or swallowing
- Fever exceeds 101°F (38.3°C)
- There's severe pain or visible abscess formation It is essential to note that the modified Centor criteria can help determine the likelihood of a bacterial cause, and patients who meet fewer than 3 Centor criteria do not need to be tested 1.
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 in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes), with a clinical success rate of 98% at Day 14 and 94% at Day 30, and a bacteriologic eradication rate of 95% at Day 14 and 77% at Day 30 2.
- Key points:
- Azithromycin is clinically and microbiologically statistically superior to penicillin V in the treatment of pharyngitis due to GABHS.
- The most common side effects of azithromycin in the treatment of pharyngitis are diarrhea/loose stools, vomiting, and abdominal pain.
From the Research
Definition and Causes of Pharyngitis
- Pharyngitis is a common infection, with group A beta-hemolytic streptococcal pharyngitis being the most common bacterial etiology, responsible for approximately 5 to 10 percent of pharyngitis cases 3.
- The symptoms of group A beta-hemolytic streptococcal pharyngitis overlap with non-bacterial and viral causes of acute pharyngitis, complicating the problem of diagnosis 4.
Diagnosis of Pharyngitis
- Clinical findings are unreliable, and a rapid streptococcal test or a throat culture should be performed to confirm the diagnosis 5.
- A positive rapid antigen detection test may be considered definitive evidence for treatment, while a negative test should be followed by a confirmatory throat culture when streptococcal pharyngitis is strongly suspected 3.
- Clinical score systems, such as the Centor score and McIssac score, have been developed to help clinicians decide which patients should undergo diagnostic testing and reduce the unnecessary use of antimicrobials 6.
Treatment of Pharyngitis
- Treatment goals include prevention of suppurative and nonsuppurative complications, abatement of clinical signs and symptoms, reduction of bacterial transmission, and minimization of antimicrobial adverse effects 3.
- Oral penicillin remains the drug of choice in most clinical situations, although alternative treatments, such as cephalosporins and amoxicillin-clavulanate potassium, may be used in patients with penicillin allergy or treatment failure 3, 7.
- Antimicrobial therapy should be initiated without delay once the diagnosis is confirmed, with oral penicillin V and amoxicillin being the preferred choices 6.
- For patients with a non-anaphylactic allergy to penicillin, oral cephalosporin is an acceptable alternative, while patients with a history of immediate, anaphylactic-type hypersensitivity to penicillin may be treated with oral clindamycin, clarithromycin, or azithromycin 6.
Prevention of Complications
- Early diagnosis and antimicrobial treatment are recommended to prevent suppurative complications, such as cervical lymphadenitis and peritonsillar abscess, and non-suppurative complications, particularly rheumatic fever 6.
- Treatment also aims to reduce the severity of symptoms, shorten the duration of the illness, and reduce disease transmission 6.