What is the recommended treatment for a patient with suspected streptococcal pharyngitis and negative test results?

From the Guidelines

For patients with suspected streptococcal pharyngitis but negative test results, symptomatic treatment is recommended rather than antibiotics. This approach is based on the most recent and highest quality evidence available, which emphasizes the importance of avoiding unnecessary antibiotic use to prevent resistance and minimize side effects 1. The patient's presentation with a WBC count of 10.5, sore throat, and fatigue, but negative COVID, flu, and RSV tests, suggests a possible viral etiology, which is consistent with the majority of pharyngitis cases.

Symptomatic Treatment

Symptomatic treatment should include:

• Rest
• Adequate hydration
• Over-the-counter pain relievers such as acetaminophen (325-650 mg every 4-6 hours, not exceeding 3000 mg daily) or ibuprofen (400-600 mg every 6-8 hours with food)
• Warm salt water gargles (1/4 to 1/2 teaspoon of salt in 8 ounces of warm water)
• Throat lozenges containing benzocaine or menthol for temporary relief

Rationale for Avoiding Antibiotics

The use of antibiotics in patients with negative strep tests is not justified, as it contributes to antibiotic resistance and exposes patients to potential side effects without benefit 1. The Infectious Diseases Society of America recommends reserving antibiotic treatment for patients with confirmed group A streptococcal pharyngitis, and using penicillin or amoxicillin as the first-line treatment for those who are not allergic to these agents 1.

Follow-up Care

If the patient's symptoms worsen or persist beyond 7-10 days, or if they develop high fever, difficulty breathing or swallowing, or severe pain, they should seek follow-up care, as this may indicate a different condition requiring alternative treatment 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)

Approximately 1% of azithromycin-susceptible S pyogenes isolates were resistant to azithromycin following therapy.

It is recommended that there be at least 10 days’ treatment for any infection caused by Streptococcus pyogenes to prevent the occurrence of acute rheumatic fever.

The patient has a sore throat and fatigue with a WBC count of 10.5, but negative test results for COVID, flu, and RSV. Given the symptoms, the patient may have streptococcal pharyngitis.

• The recommended treatment for streptococcal pharyngitis is antibiotics, such as azithromycin or amoxicillin.
• The treatment should be continued for at least 10 days to prevent the occurrence of acute rheumatic fever.
• The patient's WBC count and symptoms should be monitored closely to determine the effectiveness of the treatment. 2 3

From the Research

Next Steps for Patient with Suspected Streptococcal Pharyngitis

• The patient has a WBC count of 10.5 with 4 days of sore throat and fatigue, but negative test results for COVID, flu, and RSV 4, 5.
• The patient's symptoms, such as sore throat and fatigue, are consistent with streptococcal pharyngitis, but the negative test results make it difficult to confirm the diagnosis 6, 7.
• Clinical decision rules, such as the modified Centor score, can be used to assess the risk of group A beta-hemolytic streptococcal infection 4, 5.
• If the patient's symptoms and physical examination suggest streptococcal pharyngitis, a throat culture may be recommended to confirm the diagnosis, especially in children and adolescents 4, 5.

Treatment Options

• Penicillin and amoxicillin are first-line antibiotics for the treatment of streptococcal pharyngitis, with a recommended course of 10 days 4, 5, 8.
• First-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 4, 5.
• Azithromycin and clarithromycin are not recommended due to significant resistance in some parts of the United States 4.
• Steroids are not recommended for symptomatic treatment of streptococcal pharyngitis 4.

Further Evaluation

• Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment should be reevaluated 4.
• Tonsillectomy is rarely recommended as a preventive measure, and the decision to perform surgery should be based on the patient's individual circumstances and medical history 4, 5.