From the Guidelines
The treatment of pharyngitis depends on its cause, with most cases being viral and requiring only supportive care, while bacterial pharyngitis, specifically Group A Streptococcus (strep throat), requires antibiotics, with first-line treatment being penicillin V or amoxicillin for 10 days. For viral pharyngitis, treatment includes rest, adequate hydration, warm salt water gargles, throat lozenges, and over-the-counter pain relievers like acetaminophen (325-650mg every 4-6 hours) or ibuprofen (400-600mg every 6-8 hours) 1.
Key Considerations
- The diagnosis of GAS pharyngitis is crucial to guide treatment, as antimicrobial therapy is only beneficial for GAS pharyngitis and not for other causes of pharyngitis 1.
- For penicillin-allergic patients, alternatives include cephalexin (if no anaphylactic reaction history), azithromycin (500mg on day 1, then 250mg daily for 4 days), or clindamycin (300mg three times daily for 10 days) 1.
- Antibiotic treatment reduces symptom duration, prevents complications like rheumatic fever and suppurative complications, and decreases transmission 1.
Treatment Options
- Penicillin V: 250-500mg orally twice daily for 10 days
- Amoxicillin: 500mg twice daily or 1000mg once daily for 10 days
- Cephalexin: for penicillin-allergic patients, 20 mg/kg/dose twice daily (max = 500 mg/dose) for 10 days
- Azithromycin: for penicillin-allergic patients, 12 mg/kg once daily (max = 500 mg) for 5 days
- Clindamycin: for penicillin-allergic patients, 7 mg/kg/dose 3 times daily (max = 300 mg/dose) for 10 days Patients should complete the full antibiotic course even if symptoms improve quickly, and if symptoms worsen or don't improve within 48-72 hours of treatment, medical reassessment is recommended 1.
From the FDA Drug Label
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 14 Day 30 Bacteriologic Eradication: Azithromycin 323/340 (95%) 255/330 (77%) Penicillin V 242/332 (73%) 206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin 336/343 (98%) 310/330 (94%) Penicillin V 284/338 (84%) 241/325 (74%)
Treatment of Pharyngitis: Azithromycin is effective in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes). The clinical success rate (cure and improvement) was 98% at Day 14 and 94% at Day 30.
- Key Points:
- Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30.
- Bacteriologic eradication rates were 95% at Day 14 and 77% at Day 30 for azithromycin.
- Clinical success rates were 98% at Day 14 and 94% at Day 30 for azithromycin. 2
From the Research
Diagnosis of Pharyngitis
- The diagnosis of pharyngitis is based on clinical evaluation and microbiologic testing 3, 4, 5, 6, 7.
- 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 5, 6, 7.
- The Centor criteria include history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis) 3, 4, 6.
Treatment of Pharyngitis
- Antibiotic treatment of adult pharyngitis benefits only those patients with Group A beta-hemolytic streptococcus (GABHS) infection 3, 4, 5, 6, 7.
- The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient 3, 4.
- First-line treatment for GABHS pharyngitis includes a 10-day course of penicillin or amoxicillin 5, 6, 7.
- Patients allergic to penicillin can be treated with first-generation cephalosporins, clindamycin, or macrolide antibiotics 5, 7.
Management of Pharyngitis
- All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care 3, 4.
- Nonsteroidal anti-inflammatory drugs are more effective than acetaminophen and placebo for treatment of fever and pain associated with GABHS pharyngitis 5.
- Corticosteroids provide only a small reduction in the duration of symptoms and should not be used routinely 5, 6.
- Tonsillectomy is rarely recommended as a preventive measure, with specific thresholds for considering surgery 6.