What is the treatment for pharyngitis?

Treatment of Pharyngitis

For pharyngitis treatment, antibiotics should only be used for confirmed or highly suspected Group A Streptococcus (GAS) infections, with penicillin V or amoxicillin as first-line therapy for 10 days, while viral pharyngitis should be managed with symptomatic relief using analgesics such as ibuprofen or paracetamol. 1

Diagnosis Before Treatment

Treatment decisions should be guided by proper diagnosis:

1. Use Centor Criteria to assess likelihood of GAS pharyngitis:

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

2. Testing recommendations:

   • Patients with 0-1 criteria: No testing or antibiotics needed 1, 2
   • Patients with 2-4 criteria: Consider Rapid Antigen Detection Test (RADT) 1
   • Viral indicators: cough, rhinorrhea, hoarseness, and oral ulcers 1

Treatment Algorithm

1. Viral Pharyngitis (80-90% of adult cases, 70-85% of pediatric cases)

• Primary treatment: Symptomatic relief 1
  • Ibuprofen: 400mg every 6-8 hours (adults), 5-10mg/kg every 6-8 hours (children)
  • Paracetamol: 500-1000mg every 4-6 hours (adults), 10-15mg/kg every 4-6 hours (children)
  • Important: Avoid aspirin in children due to risk of Reye syndrome 1
  • Maintain hydration with plenty of fluids 1

2. Bacterial Pharyngitis (GAS confirmed)

• First-line antibiotics:

  • Penicillin V: 250 mg three times daily for 10 days (adults) 1, 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, 4

• For penicillin-allergic patients:

  • Clindamycin: 300-450 mg orally three times daily for 10 days 1
  • Macrolides (e.g., Azithromycin): 12 mg/kg once daily (max 500 mg) for 5 days 1

• Important: Complete the full 10-day course of antibiotics for GAS infections to prevent acute rheumatic fever 1, 4, 3

Special Considerations

1. Children under 3 years: Testing for GAS pharyngitis usually not indicated; focus on age-appropriate symptomatic relief 1

2. Patients with renal impairment:

   • GFR 10-30 mL/min: 500 mg or 250 mg amoxicillin every 12 hours 4
   • GFR <10 mL/min: 500 mg or 250 mg amoxicillin every 24 hours 4
   • Hemodialysis: Additional dose during and after dialysis 4

3. Isolation precautions: Maintain for minimum 24 hours after starting effective antibiotic therapy 1

4. Recurrent pharyngitis management:

   • Watchful waiting if <7 episodes in past year, <5 episodes/year in past 2 years, or <3 episodes/year in past 3 years 1
   • Consider tonsillectomy for patients exceeding these thresholds with documented symptoms 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Only 5-15% of adult and 15-30% of pediatric pharyngitis cases are caused by GAS 5

2. Inadequate treatment duration: A full 10-day course of antibiotics is necessary for GAS infections to prevent complications like acute rheumatic fever 1, 4, 6

3. Inappropriate testing: Testing not recommended when clinical features strongly suggest viral etiology 1

4. Failure to provide symptomatic relief: All patients with pharyngitis should receive appropriate analgesics regardless of etiology 1, 2

5. Using tetracyclines in young children: Should not be used in children under 8 years 1

By following this evidence-based approach, clinicians can provide appropriate treatment for pharyngitis while minimizing unnecessary antibiotic use and preventing complications.