What are the symptoms and treatment options for streptococcal pharyngitis (strep throat)?

From the Guidelines

Strep throat is a bacterial infection caused by group A Streptococcus bacteria that requires antibiotic treatment, and the standard treatment is penicillin, typically amoxicillin 500mg three times daily for 10 days for adults, or 250mg three times daily for children, as recommended by the most recent guidelines 1. The symptoms of strep throat include persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates, and patients should be tested by rapid antigen detection test and/or culture for group A Streptococcus to confirm the diagnosis 1. Some key points to consider when treating strep throat include:

• Completing the entire antibiotic course, even if symptoms improve, to prevent complications like rheumatic fever or kidney inflammation 1
• Using alternative antibiotics, such as azithromycin or clindamycin, for patients allergic to penicillin 1
• Managing symptoms with analgesic therapy, such as aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs, and throat lozenges 1
• Practicing good hygiene, such as replacing toothbrushes after 24-48 hours on antibiotics, avoiding sharing utensils or drinks, and staying home until fever-free for 24 hours and on antibiotics for at least 24 hours, to prevent the spread of the infection. It's also important to note that antibiotics are not recommended for chronic group A Streptococcus carriers, as they are unlikely to spread infection to close contacts and are at little or no risk for complications 1. The treatment of strep throat should be guided by the most recent and highest quality evidence, and penicillin remains the first-line treatment for group A streptococcal pharyngitis due to its proven efficacy, safety, narrow spectrum, and low cost 1.

From the FDA Drug Label

In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum): otherwise the sequelae of streptococcal disease may occur. Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy Penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever.

The symptoms of streptococcal pharyngitis (strep throat) are not explicitly listed in the provided drug labels. Treatment options for streptococcal pharyngitis include:

• Penicillin (first-line therapy) 2
• Azithromycin (as an alternative to first-line therapy in individuals who cannot use first-line therapy) 3 3

From the Research

Symptoms of Streptococcal Pharyngitis

• Common signs and symptoms include sore throat, temperature greater than 100.4 degrees F (38 degrees C), tonsillar exudates, and cervical adenopathy 4
• Cough, coryza, and diarrhea are more common with viral pharyngitis 4

Diagnostic Tests

• Available diagnostic tests include throat culture and rapid antigen detection testing 4
• Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly 4
• The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 4

Treatment Options

• Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness 4
• Amoxicillin is equally effective and more palatable 4
• Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy 4
• Increased group A beta-hemolytic streptococcus (GABHS) treatment failure with penicillin has been reported 4, 5
• Cephalosporins may be superior to penicillin at eradicating group A beta-hemolytic Streptococcus, and several are effective when administered for 4 to 5 days 5
• Macrolides, such as clarithromycin and azithromycin, are also effective in treating streptococcal pharyngitis 6, 7
• Carbacephem may provide better symptom resolution post-treatment in adults and children compared to penicillin 8

Antibiotic Therapy

• Antibiotic therapy accelerates symptom relief (particularly fever and pain) by a day or two in patients with group A streptococcal pharyngitis 6
• A strategy based on the use of a clinical diagnostic score, followed by a rapid test if the score is intermediate, seems to be the best way of restricting antibiotics to patients with pharyngitis due to group A streptococci 6
• Immediate antibiotic therapy is justified for patients with severe symptoms or signs of progression to locoregional suppuration, and when the local incidence of acute rheumatic fever is high 6