What is the recommended treatment for acute pharyngitis?

Treatment of Acute Pharyngitis

For acute pharyngitis, penicillin or amoxicillin is the recommended first-line treatment for Group A Streptococcal (GAS) pharyngitis due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1

Diagnostic Approach

• Testing for GAS pharyngitis is not recommended for patients with clinical features suggesting viral etiology (e.g., cough, rhinorrhea, hoarseness, oral ulcers) 1
• Diagnostic testing with rapid antigen detection test (RADT) or throat culture should be performed to confirm GAS pharyngitis before initiating antibiotics 2
• A positive RADT is diagnostic and does not require backup culture 2
• Diagnostic testing is not indicated for children under 3 years old due to the rarity of acute rheumatic fever and uncommon presentation of streptococcal pharyngitis in this age group 1

Treatment Recommendations for Confirmed GAS Pharyngitis

First-Line Treatment Options

• Oral penicillin V: 250 mg four times daily or 500 mg twice daily for 10 days 2
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 3
• Intramuscular benzathine penicillin G: 1.2 million units as a single dose for patients ≥27 kg; 600,000 units for patients <27 kg 1

Treatment for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy:

  • First-generation cephalosporins for 10 days 1:
    • Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose)
    • Cefadroxil: 30 mg/kg once daily (maximum 1 g)

• For anaphylactic penicillin allergy 1, 4:

  • Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days
  • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days
  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days

Clinical Response and Follow-up

• Clinical improvement should be expected within 24-48 hours after starting antibiotic therapy 5
• Patients are generally considered non-contagious after 24 hours of antibiotic therapy 5
• If symptoms do not improve within 48-72 hours, consider alternative diagnosis or concomitant viral infection 5
• Follow-up throat cultures or RADT are not recommended routinely after treatment 1
• The full 10-day course of antibiotics (except for azithromycin) must be completed to ensure eradication of the organism from the pharynx and prevent complications such as acute rheumatic fever 5, 3

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 1
• Aspirin should be avoided in children due to the risk of Reye syndrome 1
• Corticosteroid therapy is not recommended for routine use in GAS pharyngitis 1

Common Pitfalls to Avoid

• Treating without confirming diagnosis through testing, as clinical features alone cannot reliably distinguish between viral and bacterial pharyngitis 2
• Discontinuing antibiotics prematurely when symptoms improve, which can lead to treatment failure and potential complications 5
• Using broad-spectrum antibiotics unnecessarily when narrow-spectrum options are effective 1
• Failing to distinguish between true recurrent infections and chronic carriage with viral infections in patients with multiple episodes 1
• Using macrolides (azithromycin and clarithromycin) in areas with high resistance rates 4, 6

Special Considerations

• For recurrent streptococcal pharyngitis, confirm each episode with RADT or throat culture 4
• Diagnostic testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1
• Tonsillectomy solely to reduce the frequency of GAS pharyngitis is not recommended 1