What is the treatment for acute pharyngitis?

Treatment of Acute Pharyngitis

The treatment for acute pharyngitis should be guided by the causative organism, with penicillin V remaining the first-line therapy for Group A Streptococcal (GAS) pharyngitis, administered for 10 days to prevent complications such as acute rheumatic fever. 1

Diagnostic Approach

• Most cases of acute pharyngitis (70-80%) are viral in origin and do not require antibiotic therapy 2, 3
• Group A Streptococcus (GAS) is the most common bacterial cause of pharyngitis and the primary bacterial pathogen requiring specific treatment 1, 3
• Clinical features alone cannot reliably distinguish between viral and bacterial causes, necessitating laboratory confirmation 1, 4
• Diagnosis should be confirmed using either:
  • Rapid antigen detection test (RADT) - a positive result is diagnostic and does not require backup culture 1, 5
  • Throat culture - considered the gold standard for diagnosis 3

Treatment Recommendations for GAS Pharyngitis

First-line Treatment

• Penicillin V (oral) for 10 days remains the treatment of choice due to its proven efficacy, safety, narrow spectrum, and low cost 1, 6
• Intramuscular benzathine penicillin G as a single dose is recommended for patients unlikely to complete a full 10-day course of oral therapy 1

For Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy:
  • First-generation cephalosporins (e.g., cephalexin 20 mg/kg twice daily, maximum 500 mg per dose for 10 days) 1, 5
• For anaphylactic penicillin allergy:
  • Clindamycin (7 mg/kg three times daily, maximum 300 mg per dose for 10 days) 1, 5
  • Macrolides such as:
    • Azithromycin (12 mg/kg once daily, maximum 500 mg for 5 days) 1, 7
    • Clarithromycin (7.5 mg/kg twice daily, maximum 250 mg per dose for 10 days) 1, 5

Treatment Goals

• Prevent acute rheumatic fever and suppurative complications (e.g., peritonsillar abscess) 1
• Reduce clinical symptoms and duration of illness 1, 3
• Decrease contagiousness and prevent transmission to close contacts 1
• Allow rapid resumption of normal activities 1

Non-GAS Pharyngitis

• Viral pharyngitis is self-limiting and requires only symptomatic treatment 1, 2
• Group C and G streptococci can cause pharyngitis with similar clinical features to GAS, but are not associated with acute rheumatic fever 1, 8
• Antimicrobial therapy for non-GAS bacterial pharyngitis has no proven benefit except in rare cases (e.g., Corynebacterium diphtheriae, Neisseria gonorrhoeae) 1

Symptomatic Treatment

• Acetaminophen or NSAIDs for pain relief and fever reduction 5
• Avoid aspirin in children due to risk of Reye syndrome 5
• Corticosteroids are not recommended for routine use in pharyngitis 1, 5

Management of Recurrent Episodes

• Consider whether the patient has true recurrent infections or is a chronic carrier experiencing viral infections 1, 5
• Chronic carriers (positive throat cultures without clinical or immunologic response to GAS) generally do not require antibiotic treatment 1
• For true recurrent GAS pharyngitis, options include:
  • Clindamycin (20-30 mg/kg/day in 3 doses, maximum 300 mg/dose for 10 days) 1
  • Penicillin plus rifampin 1
  • Amoxicillin-clavulanate 1

Common Pitfalls to Avoid

• Treating pharyngitis without confirming the diagnosis with RADT or throat culture 1, 4
• Prescribing antibiotics for viral pharyngitis 1, 2
• Using broad-spectrum antibiotics unnecessarily when narrower spectrum options would be appropriate 8, 5
• Failing to complete the full course of antibiotic therapy, which may lead to treatment failure 1, 9
• Recommending tonsillectomy solely to reduce the frequency of GAS pharyngitis 1