What is the recommended treatment for pharyngitis?

Treatment of Pharyngitis

For pharyngitis caused by Group A Streptococcal (GAS) infection, oral penicillin V (250mg 2-3 times daily for children, 500mg 2-3 times daily for adults) or amoxicillin (50mg/kg once daily or 25mg/kg twice daily) for 10 days are the recommended first-line treatments. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

1. Use the Centor criteria to assess likelihood of GAS infection:

   • Fever by history
   • Tonsillar exudates
   • Tender anterior cervical adenopathy
   • Absence of cough 1

2. Testing recommendations:

   • Patients with 0-2 Centor criteria: No testing needed (likely viral)
   • Patients with 3-4 Centor criteria: Test with rapid antigen detection test (RADT) and/or throat culture 1

Treatment Algorithm

First-Line Treatment (GAS Pharyngitis)

• Children:

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

• Adults:

  • Penicillin V: 500mg 2-3 times daily for 10 days OR
  • Amoxicillin: Similar adult dosing for 10 days 1

For Penicillin-Allergic Patients

• Narrow-spectrum oral cephalosporins (cefadroxil or cephalexin) for 10 days
  • Note: Cross-reactivity occurs in about 10% of penicillin-allergic patients 1
• Clindamycin: 7mg/kg three times daily (max 300mg per dose) for 10 days 1
• Macrolides (e.g., azithromycin): 12mg/kg once daily (max 500mg) for 5 days 1, 2
  • Note: While azithromycin has shown clinical success rates comparable to penicillin (95% vs 97%), bacteriological eradication rates are significantly lower (38% vs 81%) 3

Special Considerations

• Benzathine penicillin G is reserved for:
  • Non-compliance with oral therapy
  • Personal or family history of rheumatic fever
  • High-risk environmental settings
  • Areas where rheumatic fever remains prevalent 1

Symptomatic Treatment

• NSAIDs (e.g., ibuprofen): First-line for pain and fever management
• Acetaminophen: Alternative for pain and fever
• Warm salt water gargles
• Throat lozenges used every two hours 1, 4

Important Clinical Pearls

1. Complete the full course: Patients must complete the full 10-day course of antibiotics even if symptoms improve quickly 1

2. Return to normal activities: Patients are considered non-contagious after 24 hours of appropriate antibiotic therapy 1

3. Avoid once-daily penicillin: Studies show that once-daily penicillin V results in higher bacteriologic failure rates (22%) compared to multiple daily doses (8%) 5

4. Twice-daily dosing acceptable: Research suggests that penicillin V given twice daily is as effective as three-times-daily dosing 6

5. Follow-up recommendations: Routine follow-up is not necessary for uncomplicated pharyngitis, but patients should return if:

   • Symptoms persist beyond 7 days
   • Difficulty swallowing or breathing develops
   • High fever persists despite antipyretics
   • Purulent tonsillar exudates or tender cervical lymphadenopathy develops 1

Common Pitfalls to Avoid

1. Undertreatment: Failing to complete the full 10-day course of antibiotics can lead to treatment failure and complications

2. Overdiagnosis: Not all sore throats are bacterial - GAS causes only 15-30% of pharyngitis in children and 5-15% in adults 4

3. Inappropriate antibiotic selection: Using broad-spectrum antibiotics unnecessarily when narrow-spectrum options are preferred

4. Routine use of corticosteroids: These provide only minimal reduction in symptom duration and should not be used routinely 4