What is the treatment for pharyngitis?

Treatment of Pharyngitis

Penicillin or amoxicillin is the recommended first-line treatment for Group A Streptococcal (GAS) pharyngitis, administered for 10 days to eradicate the organism from the pharynx. 1

Diagnosis Before Treatment

• Pharyngitis should not be treated empirically based on clinical symptoms alone, as most cases are viral in nature 2
• Testing for GAS pharyngitis is recommended using either:
  • Rapid antigen detection test (RADT) 1
  • Throat culture (gold standard) 3
• A positive RADT confirms GAS etiology and justifies antibiotic treatment 1
• For adults, a negative RADT does not require confirmation with throat culture 2
• For children and adolescents, a negative RADT should be confirmed with throat culture due to higher risk of complications 2

First-Line Treatment

• Penicillin V or amoxicillin for 10 days is the treatment of choice for GAS pharyngitis 1
  • Penicillin is preferred due to its narrow spectrum, low cost, and proven efficacy 4
  • A full 10-day course is required to achieve maximal pharyngeal eradication of GAS 1
• For patients unlikely to complete a full 10-day oral course, intramuscular benzathine penicillin G is preferred 4

Treatment for Penicillin-Allergic Patients

• For patients with non-anaphylactic penicillin allergy:
  • First-generation cephalosporins for 10 days 1, 5
• For patients with severe or immediate penicillin allergy:
  • Clindamycin for 10 days 1, 5
  • Clarithromycin for 10 days 1
  • Azithromycin for 5 days (shorter course due to prolonged tissue half-life) 1, 6

Adjunctive Therapy

• Analgesics/antipyretics are recommended for symptom relief 1:
  • Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1
  • NSAIDs may be more effective than acetaminophen for pain and fever relief 7
• Aspirin should be avoided in children due to risk of Reye syndrome 1
• Corticosteroids are not recommended as adjunctive therapy 1

Management of Non-Streptococcal Pharyngitis

• Most cases of pharyngitis (70-95%) are viral and self-limiting 7, 8
• Withhold antibiotics for patients with negative tests for GAS 2
• Provide symptomatic therapy only for viral pharyngitis 2

Management of Recurrent Episodes

• For patients with recurrent GAS pharyngitis, consider:
  • They may be experiencing true recurrent infections 1
  • They may be chronic GAS carriers experiencing viral infections 1
• For multiple recurrences, alternative antibiotics may be considered:
  • Clindamycin (20-30 mg/kg/day in 3 doses for 10 days) 1
  • Amoxicillin-clavulanic acid (40 mg/kg/day in 3 doses for 10 days) 1

Important Considerations

• Patients are considered non-contagious after 24 hours of appropriate antibiotic therapy 4
• Routine post-treatment throat cultures are not recommended for asymptomatic patients 1
• Follow-up testing should only be considered in special circumstances, such as patients with a history of rheumatic fever 4
• Macrolide resistance among GAS varies geographically, with rates around 5-8% in the United States 5

Potential Pitfalls

• Treating based on clinical symptoms alone leads to antibiotic overuse 2
• Shortening the course of penicillin treatment increases the risk of treatment failure 1
• Switching antibiotics without microbiological indication increases the risk of adverse effects 2
• Not confirming negative RADT results with throat culture in children may miss 10-20% of true GAS infections 3