What is the prescription for acute pharyngitis?

From the Guidelines

For acute pharyngitis, the prescription should be penicillin V (500mg twice daily for 10 days) as the first-line antibiotic, with alternatives including azithromycin (500mg once daily for 5 days) or clindamycin (300mg three times daily for 10 days) for penicillin-allergic patients, as supported by the most recent and highest quality study 1.

Key Considerations

• The cause of pharyngitis determines the treatment approach, with viral pharyngitis being treated supportively and bacterial pharyngitis, particularly Group A Streptococcus, requiring antibiotic therapy.
• Penicillin V is the recommended first-line antibiotic due to its narrow spectrum of activity, infrequency of adverse reactions, and modest cost, as stated in 1 and 1.
• For penicillin-allergic patients, alternatives such as azithromycin or clindamycin are recommended, with specific dosing regimens outlined in 1.
• Completing the full antibiotic course is crucial to prevent complications like rheumatic fever, as emphasized in 1 and 1.
• Supportive care, including analgesics like acetaminophen or ibuprofen, hydration, and rest, is essential for managing symptoms, as noted in 1 and 1.

Treatment Options

• Penicillin V: 500mg twice daily for 10 days
• Azithromycin: 500mg once daily for 5 days
• Clindamycin: 300mg three times daily for 10 days
• Amoxicillin: 500mg three times daily for 10 days, often preferred for children due to better taste, as mentioned in 1 and 1.

Important Notes

• Antibiotic therapy should only be initiated upon confirmation of bacterial pharyngitis, particularly Group A Streptococcus, as stated in 1 and 1.
• The typical course of a sore throat is less than 1 week, and antibiotics are usually not needed for viral pharyngitis, as noted in 1 and 1.

From the FDA Drug Label

Pharyngitis/Tonsillitis The recommended dose of azithromycin for children with pharyngitis/tonsillitis is 12 mg/kg once daily for 5 days.

PEDIATRIC DOSAGE GUIDELINES FOR PHARYNGITIS/TONSILLITIS (Age 2 years and above, see PRECAUTIONS—Pediatric Use.) Based on Body Weight PHARYNGITIS/TONSILLITIS: (5-Day Regimen) Dosing Calculated on 12 mg/kg/day for 5 days. Weight200 mg/5 mLTotal mL per Treatment CourseTotal mg per Treatment Course KgLbs.Day 1–5 8182.5 mL (½ tsp) 12.5 mL500 mg 17375 mL (1 tsp) 25 mL1000 mg 25557.5 mL (1½ tsp) 37.5 mL1500 mg 337310 mL (2 tsp) 50 mL2000 mg 408812.5 mL (2½ tsp) 62.5 mL2500 mg

The prescription for acute pharyngitis is 12 mg/kg of azithromycin once daily for 5 days for children aged 2 years and above 2. The dosage is calculated based on body weight, with the following guidelines:

• 8-17 kg: 2.5 mL (½ tsp) per day for 5 days, total 12.5 mL, 500 mg
• 17-25 kg: 5 mL (1 tsp) per day for 5 days, total 25 mL, 1000 mg
• 25-35 kg: 7.5 mL (1½ tsp) per day for 5 days, total 37.5 mL, 1500 mg
• 33-40 kg: 10 mL (2 tsp) per day for 5 days, total 50 mL, 2000 mg
• 40 kg and above: 12.5 mL (2½ tsp) per day for 5 days, total 62.5 mL, 2500 mg Note: Safety and effectiveness in the treatment of pediatric patients with pharyngitis/tonsillitis under 2 years of age have not been established 2.

From the Research

Prescription for Acute Pharyngitis

The prescription for acute pharyngitis depends on the cause of the infection.

• For group A streptococcal pharyngitis, the standard therapy is penicillin V for 10 days 3, 4, 5.
• However, there are drawbacks to penicillin V therapy, including the length of the dosing regimen, which can lead to poor compliance and treatment failures 3.
• Alternative treatments include azithromycin, which has been shown to be effective in eradicating group A streptococci with a total dose of 60 mg/kg given over 3 or 5 days 3.
• Other antibiotics, such as oral cephalosporins or the amoxicillin-clavulanic acid combination, may also be used in cases of recurrent pharyngitis or penicillin allergy 4.
• The choice of antibiotic and duration of treatment should be based on the severity of symptoms, the presence of group A streptococci, and the risk of complications such as rheumatic fever 6, 7, 5.

Treatment Duration and Intensity

• A study comparing penicillin V treatment for 5 or 10 days found that patients with a Centor Score of 3 or 4 who received treatment for 5 days recovered earlier than those who received treatment for 10 days 7.
• Intense treatment with penicillin V four times a day for 5 days may be a beneficial treatment strategy for group A streptococcal pharyngitis, regardless of the Centor Score 7.
• However, the evidence for the optimal duration of treatment is not conclusive, and the decision to treat should be based on individual patient factors and the risk of complications 6, 5.

Antibiotic Resistance and Stewardship

• The overuse and misuse of antibiotics have contributed to the increasing problem of antimicrobial resistance 5.
• Antibiotics should only be prescribed for proven group A streptococcal pharyngitis, and narrow-spectrum antibiotics such as penicillin or amoxicillin should be used whenever possible 5.
• The number needed to treat to prevent one case of rheumatic fever is likely very large, and the decision to treat should be based on individual patient factors and the risk of complications 5.