What is the treatment for acute pharyngitis?

Treatment of Acute Pharyngitis

For acute pharyngitis, penicillin or amoxicillin remains the first-line antibiotic treatment for confirmed Group A Streptococcal (GAS) infections, while symptomatic treatment with NSAIDs or acetaminophen is recommended for pain and fever management in all cases. 1

Diagnostic Approach

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

1. Clinical Assessment using Centor Criteria:

   • Fever history
   • Absence of cough
   • Tonsillar exudates
   • Tender anterior cervical lymphadenopathy

2. Testing Recommendations:

   • 0-1 Centor criteria: No testing or antibiotics needed
   • 2+ Centor criteria: Perform rapid antigen detection test (RADT) or throat culture 1, 2

3. Testing is not recommended when:

   • Symptoms strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers)
   • Children under 3 years of age (unless specific risk factors exist) 1

Treatment Algorithm

1. Confirmed GAS Pharyngitis

First-line antibiotics:

• Penicillin V:
  • Children: 250 mg 2-3 times daily for 10 days
  • Adults: 250 mg 4 times daily or 500 mg twice daily for 10 days 1, 2, 3
• Amoxicillin:
  • 50 mg/kg once daily (max 1000 mg) or
  • 25 mg/kg twice daily (max 500 mg per dose) for 10 days 1, 2

For penicillin-allergic patients:

• First-generation cephalosporins (if not anaphylactically sensitive): For 10 days
• Clindamycin: 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days
• Clarithromycin: 7.5 mg/kg/dose twice daily (max 250 mg/dose) for 10 days
• Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 1, 4

2. Symptomatic Treatment (for all pharyngitis cases)

• NSAIDs (e.g., ibuprofen) or acetaminophen for pain relief and fever reduction 1, 5
• Avoid aspirin in children due to risk of Reye syndrome 1, 2
• Topical remedies: Lozenges, warm salt water gargles (for patients old enough to gargle) 1

Important Considerations

1. Complete the full antibiotic course: The full 10-day course (or 5 days for azithromycin) should be completed to prevent complications 2

2. Corticosteroids are not recommended for routine treatment of acute pharyngitis 1

3. Follow-up:

   • Routine post-treatment testing is not recommended 1
   • Patients should return if symptoms worsen or fail to improve within 48-72 hours of antibiotic initiation 2

4. Recurrent GAS pharyngitis:

   • Consider whether patient is experiencing true recurrent infections or is a chronic carrier with viral infections 1
   • Chronic carriers generally do not require antimicrobial therapy 1
   • Tonsillectomy is not recommended solely to reduce frequency of GAS pharyngitis 1

Evidence Quality and Considerations

The recommendation for penicillin as first-line therapy is based on strong evidence and clinical guidelines. Despite the availability of newer antibiotics, penicillin remains the drug of choice due to:

• Narrow spectrum of activity
• Low incidence of adverse reactions
• No documented resistance of GAS to penicillin 1, 6
• Modest cost 1

NSAIDs have demonstrated superior efficacy in reducing fever and pain compared to placebo in randomized controlled trials, making them appropriate first-line symptomatic treatment 1, 5.

Pitfalls to Avoid

1. Overuse of antibiotics: Most cases of pharyngitis (80-90%) are viral and do not require antibiotics 7, 8

2. Inadequate pain management: Pain relief is essential and should be provided regardless of etiology

3. Inappropriate antibiotic selection: Using broad-spectrum antibiotics when penicillin would be effective

4. Incomplete antibiotic course: Not completing the full course increases risk of complications and recurrence

5. Treating without testing: Empiric antibiotic treatment without confirming GAS infection contributes to antibiotic resistance

By following this evidence-based approach, clinicians can effectively manage acute pharyngitis while minimizing unnecessary antibiotic use and ensuring optimal patient outcomes.