What is the treatment for pharyngitis?

Treatment of Pharyngitis

Penicillin or amoxicillin is the first-line treatment for Group A Streptococcal (GAS) pharyngitis, administered for a full 10-day course to eradicate the organism from the pharynx. 1

Diagnostic Approach

Before initiating treatment, it's essential to determine whether the pharyngitis is bacterial or viral:

1. Clinical Assessment:

   • Suggestive of GAS: Fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough 2
   • Suggestive of viral etiology: Cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis, diarrhea 1, 3

2. Testing:

   • Testing is not recommended if clinical features strongly suggest viral etiology 1
   • For suspected GAS pharyngitis, use rapid antigen detection test (RADT) 2
   • In children and adolescents, negative RADT should be confirmed with throat culture 1
   • Testing is generally not indicated for children <3 years old due to low risk of rheumatic fever 1

Treatment Algorithm for Pharyngitis

1. For GAS Pharyngitis

First-line antibiotics (non-allergic patients):

• Penicillin V: 10-day course 1
• Amoxicillin: 10-day course (equally effective, better taste) 1

For penicillin-allergic patients:

• Non-anaphylactic allergy: First-generation cephalosporins (e.g., cephalexin, cefadroxil) for 10 days 1
• Anaphylactic allergy:
  • Clindamycin for 10 days 1
  • Clarithromycin for 10 days 1
  • Azithromycin for 5 days 1, 4

2. For Viral Pharyngitis

• Symptomatic treatment only

3. Adjunctive Therapy (for both bacterial and viral)

• For moderate to severe symptoms or high fever:
  • Adults: NSAIDs (more effective than acetaminophen) 1, 5
  • Children: NSAIDs or acetaminophen 1
  • Avoid aspirin in children due to risk of Reye syndrome 1
• Medicated throat lozenges every 2 hours can provide symptomatic relief 2
• Corticosteroids are not recommended as adjunctive therapy 1, 6

Important Clinical Considerations

• Patients with GAS pharyngitis should show improvement within 3-4 days of antibiotic treatment 5
• Follow-up throat cultures after treatment are not routinely recommended 1
• Testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1
• Tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, and older fluoroquinolones should not be used for GAS pharyngitis due to resistance or ineffectiveness 1
• Broad-spectrum cephalosporins are not preferred as they are more expensive and more likely to select for antibiotic-resistant flora 1

Pitfalls to Avoid

1. Inadequate duration of therapy: A full 10-day course of antibiotics (except for azithromycin) is necessary to prevent complications like rheumatic fever 1

2. Overtreatment of viral pharyngitis: Most cases of pharyngitis are viral and do not require antibiotics 7, 5

3. Inappropriate antibiotic selection: Using broad-spectrum antibiotics when narrow-spectrum would suffice increases resistance risk 1

4. Relying solely on clinical features: Clinical features alone cannot reliably distinguish between viral and GAS pharyngitis; appropriate testing is needed 3

5. Ignoring penicillin allergy status: Always verify the nature of penicillin allergy before prescribing alternatives 1