What is the appropriate treatment for a 15-year-old patient presenting with pharyngitis, lethargy, and fatigue?

Treatment for a 15-Year-Old with Pharyngitis, Lethargy, and Fatigue

Testing for Group A Streptococcal (GAS) pharyngitis should be performed using rapid antigen detection test (RADT) and/or throat culture, and if positive, treatment with penicillin V for 10 days is recommended. 1, 2

Diagnostic Approach

• The 15-year-old patient falls within the primary age group (5-15 years) for GAS pharyngitis, making testing appropriate 1
• Symptoms of lethargy and fatigue along with sore throat could indicate either viral or bacterial etiology, necessitating laboratory confirmation 1
• Clinical features that would suggest GAS pharyngitis include:
  • Sudden onset of sore throat
  • Fever (typically 101°F-104°F)
  • Absence of cough
  • Tonsillopharyngeal erythema with or without exudates
  • Tender enlarged anterior cervical lymph nodes 1
• Features suggesting viral etiology include:
  • Presence of cough
  • Conjunctivitis
  • Coryza (runny nose)
  • Hoarseness
  • Diarrhea 1

Testing Recommendations

• For a 15-year-old with sore throat, lethargy, and fatigue, a microbiological test is required to confirm diagnosis 1
• Recommended testing options:
  • Rapid antigen detection test (RADT)
  • Throat culture (gold standard) 1
• In adolescents, a negative RADT should be followed by a throat culture due to the higher prevalence of GAS in this age group and the risk of complications if left untreated 1

Treatment Algorithm

If GAS Positive:

• First-line treatment: Penicillin V for 10 days

  • Dosing: Twice or three times daily 1, 2
  • This remains the treatment of choice due to:
    • Narrow spectrum of activity
    • Proven efficacy
    • Low cost
    • Minimal side effects 2, 3

• For penicillin-allergic patients:

  • First-generation cephalosporins (if no history of anaphylaxis to penicillin)
  • Clindamycin
  • Macrolide antibiotics 3

If GAS Negative:

• Symptomatic treatment only:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are more effective than acetaminophen for fever and pain relief 3
  • Throat lozenges used every two hours can provide topical pain relief 1
  • Adequate hydration and rest 1

Supportive Care (Regardless of Etiology)

• Analgesic therapy should be offered:
  • NSAIDs are preferred for pain and fever management 1, 3
  • Throat lozenges, salt water gargles, or other topical treatments may provide additional relief 1
• Patient education:
  • Typical course of pharyngitis is less than one week 1
  • Importance of completing the full antibiotic course if prescribed 2

Important Considerations

• GAS pharyngitis accounts for 15-30% of pharyngitis cases in children and adolescents; most cases are viral 3, 4
• Treating confirmed GAS pharyngitis is important to:
  • Reduce symptom duration (by 1-2 days)
  • Prevent complications like acute rheumatic fever (more common in children/adolescents)
  • Prevent peritonsillar abscess
  • Reduce transmission 1
• Antibiotics should not be prescribed without laboratory confirmation of GAS to avoid unnecessary antibiotic use and antimicrobial resistance 1
• Recent research suggests Group C streptococcus may cause more severe and prolonged symptoms than GAS, though treatment recommendations remain the same 5

Pitfalls to Avoid

• Do not rely solely on clinical presentation for diagnosis, as signs and symptoms of viral and bacterial pharyngitis overlap significantly 1
• Do not prescribe antibiotics empirically without testing, as this contributes to antibiotic resistance 1
• Do not discontinue antibiotics early if prescribed for confirmed GAS; complete the full 10-day course to prevent complications 2
• Do not ignore persistent or worsening symptoms, which may indicate complications or alternative diagnoses 1