Should antibiotics be continued for a sore throat if Group A Streptococcus (GAS) is negative?

From the Guidelines

Antibiotics should be discontinued for a sore throat if Group A Streptococcus (GAS) testing is negative, as the majority of non-GAS sore throats are viral in nature and do not benefit from antibiotic treatment 1. Continuing antibiotics unnecessarily can contribute to antibiotic resistance, disrupt normal gut flora, and expose patients to potential side effects without therapeutic benefit. The American College of Physicians and the Centers for Disease Control and Prevention recommend treating patients with antibiotics only if they have confirmed streptococcal pharyngitis 1.

Key Considerations

• Most sore throats are caused by viruses, and antibiotics provide no benefit in these cases 1.
• The Infectious Diseases Society of America recommends antibiotic therapy only for patients with a positive streptococcal test result 1.
• Symptomatic treatment with rest, adequate hydration, over-the-counter pain relievers like acetaminophen or ibuprofen, and throat lozenges is recommended for patients with a negative GAS result 1.
• Exceptions to discontinuing antibiotics may include strong clinical suspicion of another bacterial infection or specific risk factors such as immunocompromise or history of rheumatic fever.

Management Strategies

• Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis using rapid antigen detection test and/or culture for group A Streptococcus 1.
• Patients with confirmed streptococcal pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days) 1.
• Penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents, while alternative antibiotics such as azithromycin may be used for penicillin-allergic patients 1.

From the Research

Diagnosis and Treatment of Sore Throat

• The decision to continue antibiotics for a sore throat if GAS (Group A Streptococcal) negative should be based on clinical guidelines and diagnostic test results 2, 3, 4, 5, 6.
• According to the studies, clinical decision rules and rapid antigen testing can help assess the risk of GAS infection and guide antibiotic prescription 2, 4, 5, 6.
• If a rapid antigen test result is negative, a throat culture is recommended in children and adolescents to confirm the absence of GAS infection 2.
• Antibiotics are only modestly beneficial in treating sore throat, and their effectiveness increases in people with positive throat swabs for GAS 3.
• The use of antibiotics should be guided by diagnostic testing, and clinicians should follow current guidelines to minimize inappropriate antibiotic use 2, 3, 4, 5, 6.

Antibiotic Prescription

• The studies suggest that antibiotic prescription rates are high, even when diagnostic testing is negative or not performed 3, 6.
• Pediatricians are less likely to prescribe antibiotics than other providers, regardless of patient age 6.
• The use of nucleic acid amplification testing (NAAT) or rapid antigen detection test (RADT) plus culture can help lower the incidence of inappropriate antibiotic use 6.

Clinical Decision-Making

• Clinical decision rules, such as the Centor criteria, can help guide antibiotic prescription, but their accuracy is limited 4.
• Adjunctive point-of-care testing can provide sufficient accuracy to guide antibiotic prescription on first presentation 4.
• Clinicians should consider the benefits and risks of antibiotic treatment and follow current guidelines to ensure appropriate management of sore throat 2, 3, 5, 6.